Columma  ©ntoemtp 

m  tfce  Cttp  of  JSeto  gorfe  V^^> 
>rf)ool  of  Bental  anb  ©ral  g>ur§&)( 


Reference  Ltbrarp 


A  TEXT-BOOK 

OF 

GENITOURINARY   DISEASES 
CASPER 


PRESS  REVIEWS  OF  PREVIOUS  EDITIONS 


From  The  London  Lancet. 

"  The  name  of  Prof.  Casper  is  sufficient  in  itself  to  guarantee  the  high 
quality  of  any  work  dealing  with  the  branch  of  surgery  with  which  his  name 
is  associated.  The  original  German  edition  of  this  work  is  known  all  ovc 
the  world  as  a  standard  treatise  on  genito-urinary  affections. 

"  We  may  say  at  once  that  the  translation  has  been  well  done,  so  that  it 
reads  almost  as  an  original  work.  The  translator's  additions  are  judicious. 
We  can  speak  very  favorably  of  Casper's  treatise  in  its  English  dress;  it 
should  prove  useful  to  many." 

From  The  Johns  Hopkins  Bulletin. 

"The  book  is  concise  and  should  be  very  useful  for  students.  The  addi- 
tions which  Dr.  Bonney  has  made  to  the  German  edition  have  distinctly 
increased  the  value  of  the  book." 

From  The  Medical  Record. 

"The  translator  and  the  publishers  of  this  volume  have  rendered  a  com- 
mendable service  to  English-speaking  readers  in  presenting  an  English 
version  of  Casper's  text-book,  which  represents  the  technic  of  one  who  for 
some  years  has  been  regarded  as  an  authority  of  the  greatest  eminence  in 
his  field." 

From   The   American   Journal   of    Dermatology   and    Genito-Urinary 
Diseases. 

"The  present  work  has  a  double  value  from  the  fact  that  it  has  been 
written  by  an  acknowledged  authority  on  the  subject  whereof  he  speaks  and, 
in  the  second  place,  in  that  it  has  been  edited  by  such  a. competent  genito- 
urinaiy  surgeon.  It  is  written  in  a  thorough,  conscientious  manner,  with  a 
little  inclination  to  be  conservative,  and  it  can  be  safely  recommended  as  a 
reliable  guide,  both  to  physicians  and  students.  As  a  text-book,  it  certainlv 
stands  as  the  peer  of  any." 

From  The  New  Orleans  Medical  and  Surgical  Journal. 

"  One  of  the  best  texts  on  the  subject,  it  is  a  fortunate  thing  that  it  has 
been  placed  at  the  command  of  English-speaking  readers.  The  diction  is 
simple,  the  system  good,  the  illustrations  numerous  and  selected  for  their 
practical  utility.  Besides,  we  have  the  experience  of  Casper  given  with  the 
authority  of  a  master.  Dr.  Bonney  has  done  well  his  work  as  translator, 
and  has  furnished  valuable  annotations  and  additions.  The  book  is  to  be 
sincerely  commended  and  also  heartily  recommended  to  our  readers." 

From  The  Dublin  Journal  of  Medical  Science. 

"We  can  confidently  recommend  the  treatise  as  one  of  the  soundest  and 
best  we  have  ever  read  in  connection  with  this  important  subject.  The 
translation  is  well  done  and  reads  pleasantly  and  smoothly." 

From  The  Annals  of  Surgery. 

"  The  book  is  eminently  practical,  and  will  rank  high  among  the  text- 
books on  Genito-Urinary  Diseases." 


A  TEXT-BOOK 

OF 

GENITO-URINARY 
DISEASES 

Including  Functional  Sexual  Disorders  in  Man 

BY 

DOCTOR  LEOPOLD  CASPER 

Professor  in  the^University  of  Berlin 

Translated  and  Edited  with  Additions 

BY 

CHARLES  W.  BONNEY,  B.  L.,  M.  D. 

Assistant  Demonstrator  of   Anatomy,  Jefferson    Medical    College,  Formerly  Surgeon  to 
the  Southern  Dispensary,  Philadelphia,  etc. 

Second  Edition,  Revised  and  Enlarged 


WITH  230  ILLUSTRATIONS  AND  24  FULL-PAGE  PLATES, 
OF  WHICH  8  ARE  IN  COLORS 


PHILADELPHIA 

P.   BLAKISTON'S  SON  &  CO. 

1012    WALNUT    STREET 

1912 
uc  b03j 


Copyright,  1909,  by  P.  Blakiston's  Son  &  Co. 


a 
.bo* 


Printed   by 

The  Maple  Press 

York,  Pa. 


TO 

FRANZ    KONIG, 

PROFESSOR    OF    SURGERY   AND    MEDICAL 

PRIVY    COUNSELLOR, 

THIS    VOLUME    IS    DEDICATED 

AS    A    TOKEN    OF    ESTEEM. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/textbookofgenitoOOcasp 


AUTHOR'S  PREFACE  TO  THE 
TRANSLATION. 

The  cordial  relations  which  have  long  existed  between  Germany 
and  America,  and  which  it  has  recently  been  endeavored  to  make 
more  intimate ,  are  better  expressed  by  acts  than  by  words.  Accord- 
ingly it  affords  me  great  pleasure  to  see  my  Text-Book  of  Urology 
appear  in  American  vesture. 

An  English-speaking  surgeon  first  led  me  into  the  realm  of  genito- 
urinary diseases,  and  it  is  with  a  feeling  of  satisfaction  and  gratitude 
that  I  think  of  him,  my  honored  teacher,  Sir  Henry  Thompson,  of 
London. 

Although  his  profoundly  scientific  yet  withal  eminently  practical 
publications  were  familiar  to  English-speaking  nations,  they  were 
little  known  in  Germany,  and  so,  twenty  years  ago,  I  became  his 
exponent,  translating  and  publishing  his  "  Stricture  of  the  Urethra  " 
and  "  Lectures  on  Diseases  of  the  Urinary  Organs." 

I  hope  the  following  pages  will  prove  to  my  American  and  English 
colleagues  that  Sir  Henry's  teaching  fell  upon  fertile  soil;  and  that 
they  will  show  how  urology  has  developed  both  as  to  scientific 
advancement  and  technical  improvement. 

I  take  this  opportunity  to  thank  my  colleague,  Dr.  Bonney,  for  the 
diligence,  comprehensive  knowledge,  and  unremitting  interest  which 
he  has  manifested  in  the  work  of  translating  and  editing  the  book. 

Leopold  Casper. 


PREFACE  TO  THE  SECOND  EDITION 


In  preparing  the  second  edition  of  this  book  I  have  endeavored  to 
make  a  thorough  revision,  rearranging  certain  sections  of  the  text, 
amplifying  others  and  adding  such  new  material  as  it  seemed  ad- 
visable to  incorporate. 

A  number  of  American  urethroscopes,  cystoscopes  and  other  in- 
struments have  been  described;  the  treatment  of  acute  posterior 
urethritis  and  chronic  urethritis  has  been  more  thoroughly  discussed; 
the  operation  of  circumcision  has  been  carefully  described,  chiefly  for 
the  benefit  of  the  general  practitioner,  who  is  often  called  upon  to 
perform  it;  an  article  on  the  anatomy  of  the  kidneys  has  been  written; 
syphilis  of  the  kidneys  has  been  elaborated,  and  a  considerable 
number  of  new  editorial  notes  have  been  made. 

The  revision  of  the  article  on  the  treatment  of  hypertrophy  of  the 
prostate  has  been  done  by  Professor  Casper.  His  views,  based  upon 
a  further  experience  of  two  years  with  radical  operations,  are  com- 
prehensively stated. 

A  few  new  illustrations  have  been  inserted,  for  some  of  which  I  am 
indebted  to  my  student,  Mr.  M.  L.  Elsinger. 

To  the  members  of  the  profession  who  have  received  the  book  so 
cordially,  and  to  the  reviewers  and  correspondents  who  have  ex- 
pressed such  favorable  opinions  of  it,  I  hereby  render  sincere  thanks. 

Charles  W.  Bonney. 

320    SOUTH    ELEVENTH    STREET,    PHILADELPHL4, 

January  1,   1909. 


EDITOR'S  PREFACE  TO  FIRST  EDITION. 


This  book  is  offered  to  English-speaking  practitioners  and  students 
of  medicine  with  the  belief  that  it  represents  the  best  teaching  of 
genito- urinary  diseases  which  is  at  present  available.  I  trust  they 
will  concur  in  my  opinion,  that  it  reflects  the  combined  result  of 
large  clinical  experience,  modern  methods  of  research,  and  conserva- 
tive judgment. 

Although  the  translation  is  by  no  means  literal,  yet  some  effort 
has  been  made  to  adhere  as  closely  to  the  original  text  as  clearness, 
precision,  and  the  intrinsic  idiomatic  differences  of  the  two  languages 
would  permit. 

The  discussion  of  radical  operations  for  hypertrophy  of  the  pros- 
tate has  been  rewritten  conjointly  by  the  author  and  myself.  My 
own  annotations  and  additions  have  been  placed  in  brackets.  The 
technic  of  a  few  operative  procedures  not  given  in  the  German 
edition  has  been  described,  and  many  new  illustrations  have  been 
added. 

I  desire  in  this  place  to  express  my  deep  appreciation  of  the  will- 
ing assistance  which  Professor  Casper  has  given  me  in  the  prepara- 
tion of  this  edition,  and  also  to  render  acknowledgment  to  the  numer- 
ous gentlemen  who  have  loaned  pathological  specimens  or  drawings. 
I  am  particularly  indebted  to  Professors  Keen  and  Coplin,  of  Phila- 
delphia; Young,  of  Baltimore;  and  Bransford  Lewis,  of  St.  Louis. 
I  also  wish  to  thank  the  publishers  for  many  helpful  suggestions. 


Chas.  W.  Bonney. 


320    SOUTH   ELEVENTH    STREET,    PHILADELPHIA, 

August  i,  1906. 


XI 


CONTENTS 


GENERAL  SECTION. 

PAGE 

I.  Examination  of  the  Patient 2-5 

1 .  Frequency  of  Micturition 2 

2.  Changes  in  the  Urinary  Stream 3 

3.  Pain 4 

4.  Admixture  of  Blood  with  the  Urine 5 

II.  Physical  Methods  of  Examination 6-54 

1.  Examination  with  Sounds  and  Catheters 6 

2.  Urethroscopy 12 

3.  Cystoscopy 22 

4.  Digital  Examination  of  the  Bladder 51 

5.  Examination  with  the  Roentgen  Rays 52 

III.  Physical,  Chemical,  and  Microscopic  Examination  of  the 

Secretions 55-84 

1.  Physical  Properties  of  the  Urine 55 

2.  Chemical  Examination  of  the  Urine. ' 57 

3.  Microscopic  Examination  of  the  Urine 68 

SPECIAL  SECTION. 

I.  Diseases  of  the  Urethra  and  Penis 85-205 

1.  Anatomy  of  the  Urethra 85 

2.  Urethritis ' 88 

3.  Lymphangitis  and  Lymphadenitis 100 

4.  Folliculitis,  Perifolliculitis,  and  Periurethral  Abscess  ....  100 

5.  Paraurethral  Fistulae 100 

6.  Cowperitis  and  Pericowperitis 101 

7.  Extragenital  Complications  of  Gonorrhoea 101 

8.  Treatment  of  Urethritis 109 

9.  Chancroid  of  the  Urethra 129 

10.  Acuminated  Condylomata  of  the  Urethra 130 

11.  Syphilis  of  the  Urethra 130 

12.  Stricture  of  the  Urethra 131 

13.  Injuries  of  the  Urethra 160 

xiii 


XIV  CONTENTS. 

PAGE 

14.  Urinary  Infiltration  and  Urinary  Abscess 164 

15.  Foreign  Bodies  in  the  Urethra 166 

16.  Tumors  of  the  Urethra 172 

17.  Urethrocele 175 

18.  Tuberculosis  of  the  Urethra 175 

19.  Malformations  of  the  Urethra 176 

20.  Fistula  of  the  Urethra 183 

21.  Injuries  of  the  Penis 185 

22.  Balanitis 186 

23.  Phimosis  and  Paraphimosis 187 

24.  Chancroid 194 

25.  New  Growths  of  the  Penis 198 

26.  Elephantiasis 201 

27.  Cavernous  Infiltration  and  Induration  of  the  Penis 201 

28.  Lymphangitis 202 

29.  Lymphadenitis 203 

II.  Diseases  of  the  Urinary  Bladder 206-302 

1.  Anatomy  and  Physiology 206 

2.  Cystitis 208 

3.  Tuberculosis 226 

4.  Foreign  Bodies 248 

5.  Vesical  Calculus 250 

6.  Tumors 266 

7.  Injuries 278 

8.  Parasites 281 

9.  Valves  at  the  Neck  of  the  Bladder 282 

10.  Ulcer 283 

11.  Diverticula  and  Hernia 284 

12.  Varices 287 

13.  Malformations 287 

14.  Anomalies  of  the  Urachus 288 

15.  Prevesical  Phlegmon 290 

16.  Neuroses  of  the  Bladder 290 

III.  Diseases  of  the  Prostate  Gland 303-407 

1.  Anatomy  and  Physiology 303 

2.  Absence,  Atrophy  and  Cysts 305 

3.  Injuries 307 

4.  Inflammation 308 

5.  Hypertrophy 322 

6.  Tuberculosis    379 


CONTENTS.  XV 

PAGE 

7.  Concretions  and  Calculi 386 

8.  New  Growths 389 

9.  Syphilis 400 

10.  Parasites 401 

1 1 .  Neuroses 403 

[V.  Diseases  of  the  Testicle,  Epididymis,  Spermatic  Cord  and 

their  Coverings 408-451 

1 .  Anatomy 408 

2.  Congenital  Diseases  of  the  Scrotum  and  Testicles 409 

3.  Retention  of  the  Testicle 410 

4.  Congenita]  Hydrocele 413 

5.  Injuries  of  the  Scrotum  and  Testicle 414 

6.  Open  Wounds  of  the  Scrotum  and  Testicles 416 

7.  Eczema,  (Edema,  Erysipelas  and  Phlegmon  of  the  Scrotum. 41 6 

8.  Tumors  of  the  Scrotum  and  Tunica  Vaginalis 417 

9.  Tumors  of  the  Testicle  and  Epididymis 419 

10.  Tuberculosis  of  the  Testicle,  Epididymis  and  Vas  Deferens. 42 2 
n.  The  Operation  of  Castration 426 

12.  Syphilis  of  the  Testicle  and  Epididymis 428 

13.  Orchitis 430 

14.  Epididymitis 433 

15.  Deferenitis  or  Funiculitis 438 

16.  Acute  Hydrocele 439 

17.  Chronic  Hydrocele 440 

18.  Galactocele,  Hematocele  and  Spermatocele 446 

19.  Hydrocele  of  the  Cord 448 

20.  Varicocele 449 

V.  Diseases  of  the  Seminal  Vesicles 452-461 

1.  Anatomy 452 

2.  Examination  of  the  Seminal  Vesicles  and  their  Secretion..  .  .453 

3.  Malformations 454 

4.  Injuries 454 

5.  Acute  Spermatocystitis 455 

6.  Tuberculosis 457 

7.  Cysts  and  Hydrocele 459 

8.  Concretions 460 

9.  Tumors 46 1 

VI.  Diseases  of  the  Kidneys  and  Ureters 462-563 

1.  Anatomy  and  Physiology 462 


XVI  CONTENTS. 

PAGE 

2.  General    Considerations    Concerning   Examination    of    the 

Kidneys 467 

3.  Congenital  Malformations  and  Displacements 475 

4.  Circulatory  Disturbances 480 

5.  Hemorrhagic    Infarct;  Thrombosis  and  Embolism  of  the 

Renal  Arteries 48 1 

6.  Acute  Diffuse  Nephritis 483 

7.  Chronic  Nephritis 486 

8.  The  Nephritis  of  Pregnancy 494 

9.  Amyloid  Degeneration  of  the  Kidney 495 

10.  Fatty  Kidney 496 

11.  Pyelitis  and  Pyelonephritis 497 

12.  Hydronephrosis 505 

13.  Pyonephrosis 510 

14.  Tuberculosis  of  the  Kidney 517 

15.  Renal  and  Ureteral  Calculi 524 

16.  Tumors  of  the  Kidney 533 

17.  Tumors  of  the  Renal  Pelvis  and  Ureter 538 

18.  Cysts  of  the  Kidney 539 

19.  Movable  Kidney 541 

20.  Parasites  of  the  Kidney 544 

21.  Syphilis  of  the  Kidney 546 

22.  Peri-,  Epi-,  and  Paranephritis 549 

23.  Injuries  of  the  Kidney 550 

24.  Contusions  of  the  Kidney 551 

25.  Aneurysm  of  the  Renal  Artery 552 

26.  Neuralgia  of  the  Kidney 553 

27.  The  Operations  of  Nephrotomy  and  Nephrectomy 556 

28.  Examination  and  Diseases  of  the  Ureters 560 

VII.  Functional  Disturbances  op  the  Sexual  Organs 564-633 

1.  Physiology 564 

2.  The  Abnormal  Loss  of  Semen 573 

3.  Sexual  Neurasthenia 577 

4.  Impotentia  Virilis 582 

5.  Sterility  in  the  Male 616 

Sterilitas  e  defectu  seu  deformatione ;   aspermatism ;  azoo- 
spermia. 

6.  Index 635 


GENITOURINARY  DISEASES. 


GENERAL  SECTION. 

To  the  physician  who  has  studied  the  diseases  of  the  urinary 
organs  carefully  a  most  satisfactory  field  is  offered.  Among  these 
diseases,  as  among  all  others,  there  are  incurable  afflictions  which  baf- 
fle human  skill,  but  yet  a  large  number  of  cases  are  curable,  while  in 
others  the  experienced  and  resourceful  physician  is  able  to  bring  about 
improvement  and  assuage  the  agonizing  pain  to  which  the  patients 
are  so  frequently  subject.  Oftentimes  by  some  simple,  though  exactly 
appropriate  procedure,  he  will  be  able  to  confer  almost  instantaneous 
freedom  from  suffering.  On  the  other  hand,  the  inexperienced,  through 
improper  treatment,  may  do  great  harm,  which  perhaps  it  will  not 
be  possible  to  remedy. 

Therefore,  if  consciousness  of  being  able  to  relieve  suffering  lend 
increase  to  the  physician's  sum  of  happiness,  and  interest  in  the  study 
of  the  diseases  in  question  incite  him  to  keep  on  the  alert,  so  likewise 
should  the  realization  that  deficient  knowledge  may  lead  to  the  inflic- 
tion of  injury  awake  in  him  the  desire  thoroughly  to  master  this  branch 
of  medicine  and  surgery. 

It  scarcely  need  be  said  that  training  in  general  medicine  is  necessary 
for  the  accomplishment  of  such  a  purpose.  Only  those  who  have 
directed  their  vision  upon  the  entire  organism,  those  who  have  dealt 
not  with  a  "  part  of  the  whole",  but  with  "  the  whole  in  all  its  parts"  can 
expect  to  obtain  results;  but  he  who  adds  to  his  general  knowledge 
that  special  skill  without  which  urology  cannot  be  successfully  pursued 
will  come  little  short  of  attaining  the  object  desired.  The  acquisitions 
made  to  this  branch  of  medicine  during  the  last  decade,  acquisitions 
as  gratifying  as  they  are  great,  enable  us  in  the  majority  of  instances  to 
make  a  quick  and  exact  diagnosis.  The  whole  subject  is  summarized 
in  the  sentence:  "qui  bene  diagnoscit,  bene  curat." 

The  diagnostic  expedients  at  our  command  are :  — 
I.  Interrogation  of  the  patient. 
II.   Physical  methods  of  examination. 

III.  Chemical,  physical,  and  microscopic  examination  of  secretions 
and  excretions. 


2  GENERAL    SECTION. 

I.     INTERROGATION   OF  THE  PATIENT. 

The  interrogation  of  the  patient  is  begun  by  taking  an  accurate 
anamnesis.  It  must  be  learned  what  diseases  have  occurred  in  the 
patient's  family  and  of  what  maladies  his  near  relatives  died.  Special 
attention  must  be  given  to  tuberculosis,  rheumatic  or  gouty  affections, 
and  lithiasis,  because  they  are  diseases  in  which  heredity  plays  an 
indisputable  role.  As  to  other  incidents  of  family  history  the  rules  of 
general  medicine  are  applicable. 

Concerning  the  patient .  himself,  we  must  endeavor  to  ascertain 
whether  he  has  ever  had  gonorrhoea,  syphilis,  scarlet  fever,  or  other 
significant  diseases. 

After  having  obtained  information  concerning  the  beginning  of  his 
present  illness,  its  mode  of  onset,  its  course  and  duration,  the  special 
interrogation  of  the  patient  should  be  begun. 

This  special  interrogation  relates  to  a  series  of  symptoms  which 
are  present  in  one  form  or  another  in  a  large  number  of  diseases  of  the 
genito-urinary  tract.  Certain  ones  are  pathognomonic  of  certain  dis- 
eases. The  special  interrogation,  by  directing  our  attention  along 
definite  lines,  makes  diagnosis  more  easy,  although  we  must  not  be  led 
into  making  a  diagnosis  solely  upon  the  statements  of  the  patient  with- 
out resorting  to  the  other  methods  of  investigation  appropriate  to  his 
case.  To  do  so  would  be  only  to  fall  into  error.  The  object  of  ques- 
tioning the  patient  is  to  arrive  at  a  diagnosis,  and  we  should  avoid  ask- 
ing questions  which  are  unnecessary  and  perhaps  distasteful  to  him. 
We  are  not  justified,  however,  even  though  only  the  slightest  doubt 
exists,  in  basing  our  diagnosis  entirely  upon  this  examination. 

The  questions  to  be  asked  relate  to : 

1.  The  frequency  of  micturition. 

2.  Changes  in  the  urinary  stream. 

3.  The  presence  or  absence  of  pain. 

4.  The  admixture  of  blood  with  the  urine. 

I.    FREQUENCY  OF  MICTURITION. 

A  healthy  person  urinates  about  five  times  in  twenty-four  hours. 
As  the  normal  quantity  of  urine  voided  in  twenty-four  hours  is  about 
1500  cubic  centimeters  (50  ounces),  the  average  capacity  of  the  bladder 
may  be  given  as  300  cubic  centimeters  (10  ounces). 

It  has  been  observed  that  a  large  number  of  diseases  of  the  genito- 


CHANGES    IN    THE    URINARY    STREAM.  3 

urinary  tract  are  associated  with  increased  frequency  of  urination, 
although  in  this  respect  marked  differences  exist. 

First  of  all,  it  is  evident  that  a  distinction  must  be  made  between 
those  affections  in  which  the  quantity  of  urine  is  considerably  increased, 
and  those  in  which  no  increase  occurs.  If  the  capacity  of  the  bladder 
has  remained  intact,  patients  having  diseases  of  the  first  class  will 
naturally  urinate  more  frequently  than  healthy  persons.  Among  such 
diseases  may  be  mentioned  diabetes  mellitus,  diabetes  insipidus, 
chronic  interstitial  nephritis,  and  urina  spastica. 

In  the  second  class,  although  the  quantity  of  urine  voided  is  normal, 
increased  frequency  of  micturition  is  caused  by  inflammatory 
conditions  of  the  urinary  organs,  as  for  example,  acute  posterior 
urethritis  and  cystitis.  It  is  especially  characteristic  of  this  class 
of  diseases  that  the  urgency  of  urination  is  present  both  day  and 
night. 

In  sharp  contrast  to  these  diseases  are  the  neuroses  of  the  bladder, 
which  are  peculiar  in  that  they  cause  frequent  micturition  only  during 
the  day,  the  patients  being  able  to  hold  their  urine  throughout  the 
entire  night. 

In  hypertrophy  of  the  prostate  and  vesical  calculus  a  decided  differ- 
ence exists  between  the  number  of  urinations  which  occur  during  the 
day  and  the  night.  In  the  former  they  are  much  more  frequent  at 
night,  while  in  the  latter  patients  not  uncommonly  sleep  the  whole  night 
through  without  having  to  pass  their  water  once,  although  activity  dur- 
ing the  day  increases  the  number  of  their  urinations. 

Mere  suggestions  should  suffice  to  illustrate  the  importance  of  the 
interrogation.  In  our  discussion  of  individual  diseases  we  shall  refer 
most  frequently  to  this  symptom.  From  what  has  already  been  said  it 
will  be  seen  that  it  is  necessary  to  question  the  patient  with  the  utmost 
precision  on  this  subject.  This  may  be  done  by  asking  him  if  he 
urinates  oftener  than  a  healthy  person,  or  oftener  than  he  formerly 
urinated.  If  an  affirmative  answer  be  received,  then  it  must  be 
ascertained  whether  the  increased  frequency  exists  both  day  and  night, 
or  only  during  the  day;  whether  it  is  more  .manifest  at  one  time  than  at 
another;  and  whether  rest  or  exercise  exerts  any  influence  upon  it. 

2.    CHANGES  IN  THE  URINARY  STREAM. 

It  is  a  constant  symptom  of  every  stricture  of  the  urethra  for  the 
stream  of  urine  to  become  smaller.     This  is  so  pathognomonic  that  it 


4  GENERAL    SECTION. 

may  be  said,  the  narrower  the  stricture,  the  smaller  the  circumference  of 
the  stream.  In  the  worst  cases  there  is  no  stream  at  all,  the  urine  being 
voided  drop  by  drop. 

In  contradistinction  to  this  condition  there  is  a  symptom  which  is 
present  when  the  bladder  has  lost  its  tonicity,  or  when  an  obstruction 
exists  near  its  neck;  this  symptom  consists  in  diminution  of  the  projec- 
tile power  of  the  urinary  stream.  The  urine  can  no  longer  be  forcibly 
expelled  in  an  arched  stream,  but  falls  almost  perpendicularly  down- 
wards. This  symptom  is  observed  in  disturbance  of  the  central  nerv- 
ous system  affecting  the  vesical  centers  or  paths  of  conduction,  and 
especially  in  hypertrophy  of  the  prostate. 

In  vesical  calculus,  when  the  stones  are  small  and  movable,  urination 
may  be  suddenly  arrested  if  a  stone  is  carried  toward  the  neck  of  the 
bladder  in  such  a  manner  as  to  occlude  its  opening. 

In  conformity  with  our  knowledge  of  the  changes  which  occur  in  the 
stream,  we  should  ask  our  patients  whether  they  have  noticed  that  the 
stream  has  become  smaller,  that  it  has  lost  force,  or  that  it  has  been 
suddenly  interrupted. 

3.    PAIN. 

Pain  is  a  symptom  which  is  present  in  a  large  number  of  genito- 
urinary diseases,  and  yet  it  is  one  from  which  many  conclusions  can 
be  drawn  if  its  investigation  be  minutely  conducted.  In  the  first  place, 
we  must  get  information  concerning  the  location  of  the  pain,  whether 
it  be  in  the  region  of  the  kidneys,  over  the  bladder,  or  in  the  urethra; 
if  it  be  in  the  urethra  we  must  find  out  whether  it  be  near  the  end  of 
the  penis  or  in  the  deeper  portions.  It  must  also  be  learned  whether 
the  pain  supervenes  during  urination  or  occurs  independently  thereof, 
and  whether  exercise  increases  and  rest  lessens  it. 

The  value  of  this  interrogation  in  enabling  us  to  make  a  diagnosis  will 
become  apparent  when  we  cite,  for  example,  that  the  pain  of  renal  colic 
occurs  on  the  side  corresponding  to  the  diseased  kidney  and  radiates 
along  the  ureter  down  into  the  groin ;  that  in  vesical  calculus  it  is  most 
pronounced  at  the  end  of  the  penis;  that  in  stricture  of  the  urethra  it 
occurs  at  the  site  of  the  obstruction ;  and  that  in  hypertrophy  of  the  pros- 
tate and  prostatitis  a  dull  aching  pain  is  often  felt  in  the  perineum  and 
rectum.  Vesical  calculi  often  cause  pain  independently  of  micturition 
when  the  patient  is  moving  about,  and  also  at  the  end  of  micturition;  in 
stricture  the  pain  is  generally  felt  only  when  the  patient  urinates,  while 


ADMIXTURE  OF  BLOOD  WITH  THE  URINE.  5 

in  affections  of  the  neck  of  the  bladder  spasmodic  pain  follows  the  act 
and  lasts  for  some  time  thereafter. 

It  is  hardly  necessary  to  state  that  there  are  many  exceptions  to  these 
rules,  concerning  which  we  shall  have  something  to  say  when  discussing 
the  individual  diseases. 

4.    ADMIXTURE  OF  BLOOD  WITH  THE  URINE. 

The  question  whether  the  patient  has  ever  passed  bloody  urine  is  one 
of  great  importance.  It  is  unnecessary  to  ask  the  patient  about  the 
actual  condition  of  his  urine,  because  a  thorough  examination  of  it  can 
be  made;  but  as  there  are  many  genito- urinary  diseases  in  which  haemor- 
rhage occurs  only  at  long  intervals,  inquiry  as  to  the  former  occurrence 
of  haematuria  should  always  be  made. 

Urinary  haemorrhage  is  most  frequently  associated  with  tumors,  cal- 
culi, and  tuberculosis  of  the  kidney,  and  with  tumors  and  stone  of  the 
bladder.  Gonorrhceal  inflammation  of  the  neck  of  the  bladder  also 
often  produces  it.  In  many  cases  the  patients  cannot  give  particulars  as 
to  the  beginning  of  this  condition,  while  in  others  they  are  able  to  supply 
valuable  data. 

If  haemorrhage  always  takes  place  under  the  influence  of  motion  it  be- 
speaks the  existence  of  vesical  or  renal  calculi.  Tumors  of  the  kidney 
are  characterized  by  bleeding  which  occurs  suddenly,  comes  on  without 
apparent  cause,  lasts  a  long  time,  and  is  not  easily  controlled  by  treat- 
ment. The  influence  of  rest,  so  favorable  upon  haemorrhage  due  to 
stone,  amounts  to  nothing  in  this  form  of  haematuria.  If  haemorrhage 
supervenes  at  the  end  of  micturition,  we  may  conclude  with  reasonable 
certainty  that  the  location  of  the  disease  is  at  the  neck  of  the  bladder. 
This  form  of  haemorrhage,  called  terminal  urinary  haemorrhage,  is  typical 
of  gonorrhoeal  inflammation  at  the  neck  of  the  bladder,  but  it  has  also 
been  observed  in  vesical  calculus. 

If  the  data  obtained  by  interrogating  the  patient  as  just  described  lead 
to  the  formation  of  certain  suppositions  concerning  the  nature  of  the 
malady  with  which  we  have  to  do,  it  behooves  us  to  verify  these  sup- 
positions by  resorting  to  exact  methods  of  examination,  which  we  shall 
now  proceed  to  describe. 


PHYSICAL    METHODS    OF    EXAMINATION. 


II.     PHYSICAL  METHODS   OF  EXAMINATION. 

By  physical  methods  of  examination  are  meant  those  in  which  we 
employ  our  three  principal  senses,  hearing,  touch  and  sight,  in  a 
systematic  manner  for  obtaining  important  diagnostic  data. 

We  shall  refer  to  details  when  considering  special  diseases;  at  present 
we  shall  merely  mention  a  few  generalities. 

We  use  percussion  to  give  us  information  concerning  the  presence  of 
an  abdominal  tumor;  thus,  differentiation  between  tympany  and  dull- 
ness may  help  us  to  decide  whether  we  have  to  do  with  a  tumor  of 
the  kidney  or  with  another  kind  of  new  growth. 

Palpation  is  of  great  importance  in  the  recognition  of  diseases  of 
the  kidneys,  prostate,  testicles,  and  epididymis. 

The  sense  of  sight  renders  inspection  possible  in  the  broadest  sense 
of  the  word.  We  can  examine  the  region  of  the  kidneys  and  bladder, 
the  testicles,  etc.,  with  the  naked  eye. 

The  hidden  recesses  of  the  uro-genital  tract  early  prompted  the  pro- 
fession to  search  for  expedients  which  would  enable  us  to  use  our  sense 
of  sight  in  these  deeper  and  inaccessible  portions.  The  skill  of  modern 
times  has  brought  such  aids  to  a  high  degree  of  perfection,  and  by  their 
use  our  power  of  diagnosticating  has  been  considerably  augmented. 
We  will  now  turn  our  attention  to  these  ingenious  devices. 

I.    EXAMINATION  WITH  SOUNDS  AND  CATHETERS. 

Sounds  and  catheters  are  introduced  into  the  urethra  and  bladder 
partly  for  diagnostic  and  partly  for  therapeutic  purposes.  For  both 
it  is  fundamentally  important  to  possess  adequate  knowledge  of  the 
instruments  and  the  way  in  which  they  are  used. 

For  practical  purposes  we  differentiate  between  inflexible  instruments 
made  out  of  metal,  and  flexible  ones  such  as  vulcanized  rubber  catheters, 
and  catheters  and  sounds  made  of  silk  and  coated  with  a  mixture  of 
rubber  and  varnish.  The  vulcanized  rubber  catheters  are  generally 
called  Nelaton  catheters.  A  good  article  of  this  kind  is  the  so-called 
Jaques  patent  catheter,  although  other  excellent  ones  are  manufactured 
both  in  Germany  and  France.  They  are  not  very  durable  and  care 
should  be  taken  to  see  that  they  contain  no  cracks.  A  cracked  catheter 
should  never  be  used,  as  it  may  be  broken  off  in  the  bladder. 


EXAMINATION    WITH    SOUNDS    AND    CATHETERS.  7 

The  best  of  these  catheters  are  those  having  a  blind  end  and  a  cylin- 
drical or  slightly  conical  shape. 

For  certain  purposes  the  Nelaton  catheter  having  a  Mercier  curve 
commends  itself.  In  this  modification  the  apex  of  the  instrument  forms 
an  angle  of  250 — 400  with  the  shaft.  (Fig.  1.) 

The  varnished  instruments  are  called  for  short  silk-web  catheters, 
sounds,  or  bougies.  Excellent  qualities  are  now  on  the  market.  The 
firms  of  Vergne,  Porges,  Rondeau  Freres,  and  Eynard,  of  Paris,  and 
Ruesch,  of  Cannstatt,  prepare  a  stable,  smooth  and  readily  flexible 
article.  Cotton-woven  instruments  are  not  durable  and  therefore  are 
to  be  discarded. 

The  usual  form  in  which  these  instruments  are  used  is  with  the 
olivary  tip,  the  shaft  being  long,  the  neck  tapering,  and  the  end  expand- 
ing into  a  small  knob  resembling  an  olive  in  shape  (Fig.  2).  The 
use  of  conical  bougies,  formerly  so  much  in  vogue,  is  to  be 
deprecated,  because  they  are  difficult  of  introduction  and  may  injure 
the  urethra. 

Of  these  sounds  and  catheters  a  large  number  of  the  ones  most  fre- 
quently used  should  be  kept  on  hand;  of  the  catheters,  from  No.  12  to  20 
will  be  found  most  necessary,  while  of  the  sounds  all  sizes  will  be  re- 
quired. The  smallest  sounds,  from  No.  1  to  No.  4,  are  called  filiform 
bougies;  they  too  should  have  an  olivary  tip  (Fig.  3). 

The  silk- web  catheters  are  also  manufactured  with  the  Mercier  curve. 

Recently  silk-web  catheters  bent  into  a  pronounced  curve  have  been 
placed  upon  the  market;  they  are  very  useful  for  many  purposes  (Fig.  4). 
Finally  there  are  the  sounds  with  a  double  curve,  les  sondes  bicoudees,  as 
they  are  called  by  the  French  (Fig.  5). 

The  instruments  known  as  stricture  searchers,  or  bougies  a  boule, 
consisting  of  a  cylindrical  staff  of  uniform  size  with  a  knob  attached  to 
one  end,  though  much  used  in  France  [and  also  in  America]  may  be 
dispensed  with.  [Although  these  instruments  may  be  useful  in  locat- 
ing granular  patches  and  areas  of  infiltration  in  the  anterior  urethra, 
misleading  and  pernicious  results  have  frequently  been  obtained  by 
their  employment.  I  have  demonstrated  time  and  again  that  in  a 
normal  and  perfectly  healthy  urethra  resistance  is  encountered  as  the 
head  of  the  instrument  passes  from  the  bulbous  into  the  narrow  mem- 
branous portion,  and  have  seen  not  a  few  cases  diagnosticated  and 
treated  as  stricture  in  which  the  apparent  contraction  depended  entirely 
upon  the  natural  anatomical  structure  of  the  parts.] 


PHYSICAL    METHODS    OF    EXAMINATION. 


ii 


U 


o 


'**e*sssi 


EXAMINATION    WITH    SOUNDS    AND    CATHETERS. 


Fig.  6. 


Fig.  7. 


Fig.  10. 
Brodie's    Catheter. 


IO 


PHYSICAL    METHODS    OF    EXAMINATION. 


Metal  catheters  and  sounds  have  been  made  out  of  many  different 
materials,  such  as  lead,  tin,  silver,  and  German  silver.  It  is  unessential 
which  of  these  substances  is  chosen;  nickel  or  silver  plated  instruments 
answer  every  purpose.  The  only  thing  of  importance  is  the  curve  of  the 
instruments,  which  must  be  adapted  to  the  various  uses  to  which  they 
are  put.  In  general  they  must  fit  the  curve  which  the  urethra  makes  in 
its  fixed  part. 

Metal  instruments  having  very  short  beaks  (Fig.  6)  are  to  be  re- 
jected as  incorrect;  the  stone  searcher  is  the  only  instrument  of  this 
kind  which  it  is  permissible  to  use  (Fig.  7).  When  searching  for  stone 
it  is  necessary  to  have  a  sound  with  as  short  a  curve  as  possible,  in  order 
that  it  may  be  moved  about  freely  in  the  bladder  without  touching  the 
bladder  wall.  A  properly  curved  instrument  for  general  use  is  shown 
in  Figure  8. 

For  old  men,  especially  prostatics,  a  catheter  with  the  curve  bent 
almost  at  a  right  angle  with  the  shaft  has  done  me  good  service  (Fig.  9). 

Occasionally  even  greater  curves  are  useful  in  this  class  of  cases.  A 
catheter  devised  by  Sir  Benjamin  Brodie  is  bent  to  such  a  degree  that  its 
curve  describes  a  circle  (Fig.  10). 

Similar  purposes  are  subserved  by  the  Benique  curve,  which  is  used 
for  sounds  as  well  as  for  catheters.   (Fig.  11.) 


Fig.  11. — Catheter  with  Benique  Curve. 

Catheters  for  the  female  urethra  require  only  a  slight  degree  of  curva- 
ture.    They  are  made  of  metal,  glass,  and  celluloid. 

THE    TECHNIC    OF    CATHETERIZATION. 

It  would  be  a  fruitless  task  to  try  to  learn  the  technic  of  catheterization 
from  a  book,  as  it  can  only  be  attained  by  actual  practice.  For  this 
reason  we  shall  restrict  ourselves  to  making  a  few  necessary  allusions. 

To  pass  soft  catheters  or  sounds  the  penis  is  lifted  up  so  that  the  first 
curve  of  the  urethra  becomes  obliterated  and  then  the  instrument,  pre- 
viously well  lubricated,  is  slowly  introduced.     Slight  resistance  is  en- 


EXAMINATION    WITH    SOUNDS    AND   CATHETERS.  II 

countered  as  it  passes  out  of  the  bulb,  but  this  is  easily  overcome  by 
constant  though  slight  pressure,  the  instrument  passing  readily  into  the 
bladder.  When  using  the  Mercier  catheter  care  must  be  taken  to  have 
the  end  of  the  instrument  glide  along  the  upper  wall  of  the  urethra.  It 
is  self-evident  that  the  employment  of  any  force  is  to  be  avoided. 
This  is  the  first  principle  to  be  observed  in  the  introduction  of  any  in- 
strument into  the  urethra. 

The  passage  of  inflexible  instruments  is  performed  in  three  stages. 

In  the  first  stage  the  instrument  is  carried  to  the  bulb.  Its  outer  end 
is  held  gently  between  thumb  and  fingers  and  the  hand  is  steadied  by 
placing  the  little  finger  on  the  patient's  abdomen;  the  tip  of  the  instru- 
ment is  then  carried  toward  the  symphysis  pubis  and  the  penis  is  lifted 
up  with  the  left  hand  and  drawn  over  the  instrument.  When  the  tip 
reaches  the  bulb  the  distal  end  of  the  sound  will  have  been  removed 
from  the  abdomen  about  go°. 

In  corpulent  persons  it  is  better  to  stand  on  the  left  side  of  the  patient, 
and  holding  the  instrument  laterally  over  his  left  thigh  introduce  it 
slowly  into  the  urethra,  at  the  same  time  swinging  the  shaft  around  to 
the  median  line  of  the  abdomen.  This  manipulation  is  called  tour  de 
demi-maitre,  while  if  the  instrument  be  held  between  the  patients  thighs 
it  is  known  as  lour  de  maiire. 

During  the  second  stage  the  tip  of  the  instrument  must  pass  from  the 
bulbous  into  the  membranous  urethra.  In  order  that  it  do  so  the  distal 
end  must  be  carried  further  away  from  the  abdomen,  so  that  the  right 
angle  becomes  converted  into  an  obtuse  angle.  It  will  help  materially . 
to  press  on  the  perineum,  against  the  convexity  of  the  sound  or  catheter, 
with  the  fingers  of  the  left  hand,  thereby  bringing  the  tip  of  the  instru- 
ment up  against  the  roof  of  the  urethra  and  thus  preventing  it  from 
catching  in  the  bulb. 

When  the  catheter  enters  the  membranous  urethra  the  third  stage  of 
its  introduction  begins,  in  which  the  instrument  is  simultaneously  low- 
ered and  pushed  toward  the  patient,  its  outer  end  being  carried  down 
toward  the  thighs  as  its  tip  passes  into  the  bladder. 

It  is  of  the  greatest  importance  to  hold  the  instrument  gently  between 
the  finger  tips,  and  not  grasp  it  forcibly  with  the  hand,  as  by  holding  it 
gently  one  is  able  to  feel  whether  it  is  going  the  right  way. 

When  the  second  stage  of  catheterization  is  entered  upon,  that  is, 
when  it  is  attemped  to  pass  the  tip  of  the  catheter  into  the  membranous 
urethra,  the  instrument,  when  lowered,  will  rotate  laterally  if  its  tip 


12 


PHYSICAL    METHODS    OF    EXAMINATION. 


catches  in  the  bulb  instead  of  advancing  into  the  membranous  portion. 
If  it  be  held  firmly  in  the  hand,  rotation  cannot  take  place,  and  thus  a 
valuable  sign  as  to  whether  it  is  following  the  right  direction  is  lost. 

ASEPSIS    OF    CATHETERIZATION. 

In  this  present  age  it  is  hardly  necessary  to  state  that  the  passage  of 
any  instrument  into  the  urethra  must  be  done  under  the  strictest  aseptic 
precautions.  The  only  question  which  arises  is  how  these  precautions 
may  best  be  observed. 

In  order  to  avoid  repetition  we  will  discuss  this  question  under  asepsis 
of  cystoscopy. 

2.    URETHROSCOPY. 

Urethroscopy  is  the  term  applied  to  that  method  by  means  of  which 
the  urethra  is  illuminated  for  inspection.  Its  beginning  extends  back 
to  the  first  part  of  the  last  century.    The  large  number  of  urethroscopes 


Fig.  12. — Casper's  Electroscope. 

which  have  been  constructed  may  be  divided,  according  to  the  principle 
of  illumination  employed,  into  those  in  which  the  source  of  light  is  with- 
out the  body,  and  those  in  which  the  light  is  carried  into  the  urethra. 


URETHROSCOPY. 


13 


The  instruments  of  Bozzini,  Segelas,  Desormeaux,  Cruise,  Ftirsten- 
heim,  Grunfekl,  and  others,  all  belong  to  the  first  group.  In  1879  Nitze 
applied  the  Bruck  method  of  introducing  light  into  the  cavities  of  the 
body  to  the  urethra,  but  it  was  soon  abandoned.  Leiter,  myself,  Otis, 
and  some  others  returned  to  the  earlier  procedures,  and  constructed 
instruments  in  which  the  light  was  thrown  upon  the  mucous  mem- 
brane of  the  urethra  from  without. 

Direct  illumination  of  the  urethra,  which  was  carried  into  effect  by 
means  of  the  urethroscope  devised  by  Nitze  and  modified  by  Ober- 
lander,  depends  for  its  action  upon  the  light  derived  from  a  platinum 
-u  t>  wire  which  is  contained  within  a  tube 

introduced  into  the  urethra  and  heated 
to  a  white  heat  by  means  of  electricity. 
This  wire,  surrounded  by  a  stream  of 
water,  is  brought  close  to  the  spot  it  is 
desired  to  illuminate.  Valentine  has 
)a  recently  made  an  ingenious  change  in 
this  instrument,  having  substituted  a 
minute  Edison  lamp  for  the  platinum 
wire. 

In  the  urethroscope  dependent  upon 
reflected  light  a  strong  Edison  lamp 
generally  supplies  the  illumination.  In 
my  instrument  a  convex  lens  (Fig.  13  A) 
is  placed  over  the  Edison  lamp  (Fig.  13 
L)  for  the  purpose  of  strengthening  and 
concentrating  the  light ;  over  the  lens  a 
prism  is  placed,  which  breaks  the  light 
in  such  a  manner  as  to  cause  its  rays 
12  A)  which  is  passed  into  the  urethra 


Fig. 


-Casper's  Electroscope. 


to   fall  into   the   tube   (Fig. 
(Figures  12  and  13). 

The  view  obtained  with  this  instrument  is  so  bright  that  the  finest 
details  of  the  urethral  mucosa,  as  for  example,  its  vascular  network, 
can  be  plainly  seen.* 

[Valentine's  urethroscope  (Fig.  14),  consists  of  a  sheath,  an  obturator 
and  a  light  carrier.  After  it  is  inserted  the  obturator  is  withdrawn 
and  the  light  carrier  put  in  position.     A  lug  on  the  end  of  the  light 

*  The  electroscope  can  also  be  used  for  the  illumination  of  other  organs  if 
appropriate  adjoining  pieces  be  used  (Fig.  12  A.  K.  I.  G.) 


14 


PHYSICAL    METHODS    OF    EXAMINATION. 


carrier  fits  securely  into  a  spring  slot  in  the  disc  and  presses  against 
a  shoulder  on  its  under  side,  thus  fixing  the  light  carrier  firmly  to  the 
under  side  of  the  tube  and  preventing  it  from  crossing  the  field  of 
vision.  The  light  carriers  for  all  tubes  of  the  same  length  are  inter- 
changeable. 


Fig.  14. — Valentine's  urethroscope. 


£-** 


Fig.  15. — Koch's  urethroscope. 


In  Koch's  urethroscope  (Fig.  15)  a  small  auxiliary  tube  for  the 
light  carrier  and  lamp  is  placed  along  the  side  of  the  tube  proper. 
This  instrument  is  inserted  with  both  light  carrier  and  obturator  in 
position.  Applications  or  other  manipulations  may  be  made  directly 
to  diseased  parts  under  direct  guidance  of  the  eye.  As  the  lamp  is 
outside  the  main  tube,  it  does  not  obstruct  the  view  nor  cast  shadows, 


URETHROSCOPY. 


15 


nor  does  the  cotton  catch  on  the  lamp  when  the  applicator  is  with- 
drawn. 

Swinburne's  posterior  urethroscope  (Fig.  16),  designed  by  Dr. 
George  K.  Swinburne,  of  New  York,  consists  of  a  catheter-shaped 
tube,  16  centimeters  long,  with  a  small  auxiliary  tube  containing 
light  carrier  and  lamp  on  the  upper  side.  The  light  is  thrown 
through  a  fenestra  near  the  distal  end,  illuminating  the  floor  of  the 


Fig.  16. — Swinburne's  posterior  urethroscope. 


Fig.  17. — Dilating  bulb  to  be  used  with  Swinburne's  posterior  urethroscope. 


urethra.  The  beak  of  the  instrument  has  a  closed  end.  The  window 
attachment  shown  in  the  illustration,  when  placed  in  the  visual  end  of 
the  tube  and  connected  with  the  dilating  bulb  (Fig.  17)  allows  the 
operator  to  dilate  the  posterior  urethra,  and  thus  secure  a  more 
satisfactory  view.] 

Whatever  instrument  may  be  employed,  urethroscopy  has  only  a 
narrow  range  of  usefulness,  being  limited  by  certain  anatomical  and 
mechanical  conditions  beyond  which  the  interpretation  of  the  urethro- 
scopic   picture  is  impossible.     When   an  inflexible  tube  is  forced  be- 


1 6  PHYSICAL    METHODS    OF    EXAMINATION. 

tween  the  closely  adjacent  walls  of  the  urethra,  changes  in  the  vessels 
of  the  mucosa  are  produced  such  as  hyperaemia,  anaemia,  and  altera- 
tions in  color  and  lustre.  These  disadvantages  are  increased  during 
urethroscopy  of  the  membranous  and  prostatic  portions,  where  the 
tube  has  to  be  pressed  with  some  force  against  one  of  the  walls,  thus 
further  interfering  with  the  natural  conditions. 

These  things  must  be  borne  in  mind  and  an  endeavor  made  to  elimi- 
nate whatever  has  been  artificially  produced  before  drawing  conclusions 
concerning  the  condition  of  the  urethra.  If  such  a  course  be  pursued, 
urethroscopy  will  prove  to  be  a  diagnostic  expedient  which,  for  certain 
kinds  of  cases,  cannot  be  replaced  by  any  other  method  of  investigation 
at  our  command. 

The  technic  of  urethroscopy  is  exceptionally  simple.  Tubes  having 
obturators  and  varying  in  size  preferably  from  22  to  28  French  are 
used.  A  tube  is  selected  that  will  pass  through  the  external  meatus, 
which,  as  is  well-known,  is  the  narrowest  portion  of  the  urethra, 
without  difficulty  and  without  causing  pain.  The  larger  the  tube  the 
more  distinct  the  urethroscopic  picture,  but  a  tube  which  is  too  large 
produces  great  pain,  causes  tears  in  the  mucosa,  and  so  changes  the 
entire  picture  that  inferences  drawn  from  it  are  erroneous. 

After  the  patient  has  urinated,  the  urethra,  if  sensative,  is  cocainized 
with  a  2%  solution  of  cocain,  and  the  tube,  smeared  with  Katheter- 
purin  is  passed  slowly  and  carefully  down  to  the  bulbous  portion 
exactly  as  any  other  urethral  instrument  is  passed.  I  go  beyond  this 
limit  for  only  two  reasons;  first,  when  there  is  cause  to  suspect  the 
presence  of  a  growth  or  an  ulceration  in  the  posterior  urethra,  and 
second,  for  the  purpose  of  removing  such  a  tumor.  In  all  other  cases 
endoscopic  examination  of  the  membranous  and  prostatic  urethra  is 
to  be  avoided.  The  passage  of  a  straight  tube  beyond  the  bulb  causes 
a  stretching  of  the  pronounced  curve  which  the  urethra  here  describes. 
It  frequently  gives  rise  to  haemorrhage,  and,  moreover,  so  distorts  the 
posterior  urethra  by  the  pressure  winch  it  exerts  that  it  is  impossible  to 
distinguish  between  the  changes  produced  by  disease  and  those  pro- 
duced by  pressure  of  the  instrument. 

[These  difficulties  have  been  rendered  less  by  the  construction  of 
the  curved  posterior  urethroscope  above  described.] 

When  the  tube  reaches  the  bulb  the  obturator  is  removed,  the 
mucous  membrane  is  wiped  with  a  pledget  of  cotton  wound  around  an 
applicator,  the  urethroscope  is  set  up,  and  its  tube  placed  centrally  in 


URETHROSCOPY.  1 7 

the  long  axis  of  the  urethra.  The  tube  is  now  slowly  withdrawn  and 
the  eye  follows  the  picture  which  is  presented  until  the  external  orifice  of 
the  urethra  is  reached.  Thus  the  entire  penile  portion  of  the  urethra 
is  examined. 

In  normal  cases  the  following  picture  is  presented :  At  the  end  of 
the  tube  a  tunnel  is  seen  whose  base  is  formed  by  the  edge  of  the  tube, 
its  apex  being  further  back,  and  its  sides  being  formed  by  the  walls  of 
the  urethra.  (Griinf eld's  central  figure.)  If  the  tube  lies  in  the  long 
axis  of  the  urethra,  this  central  figure  will  form  the  center  of  the  urethro- 
scopic  picture,  having  the  form  of  a  fossette  in  the  deeper  portions, 
and  becoming  a  mere  fissure  at  the  meatus.  The  wall  of  the  tunnel  is 
formed  by  the  walls  of  the  urethra,  upon  which  the  color,  lustre, 
duplicature,  and  striation  of  the  mucous  membrane  are  to  be  observed. 

In  almost  all  parts  of  the  urethra  the  normal  color  is  white  or 
yellowish  white,  permeated  by  a  peculiar  shade  of  dark  red,  which  is 
most  intense  at  and  behind  the  bulb,  the  color  becoming  lighter  and 
lighter  as  the  meatus  is  approached ;  in  the  middle  of  the  urethra  it  is 
yellowish  red  in  hue,  while  at  the  jossa  navicularis  and  external  orifice  it 
is  pale  yellow  or  white. 

The  lustre  of  the  normal  mucosa  is  uniform  throughout,  its  upper 
surface  appearing  moist,  shiny,  and  smooth. 

When  at  rest  the  walls  of  the  urethra  lie  in  contact  with  one  another 
in  the  form  of  longitudinal  folds;  if  a  tube  be  introduced,  the  folds 
assume  a  radiate  arrangement  for  the  reason  that  the  tube  lies  perpen- 
dicularly to  a  cross  section  of  the  canal.  The  radiations  vary  according 
to  the  size  of  the  instrument  which  is  inserted:  the  smaller  the  tube, 
the  greater  the  number  of  plications,  and  vice  versa  (Figs.  18-21),  as 
pressure  of  the  tube  against  the  urethra  obliterates  them. 

In  the  spaces  between  these  folds,  striations  varying  in  color  from 
pink  to  deep  red  are  seen,  radiating  from  the  periphery  to  the  center  the 
same  as  the  folds  themselves.  These  striations  are  caused  by  blood 
vessels  in  the  submucosa.  If  the  tube  be  pressed  against  one  of  the 
urethral  walls  it  will  be  easily  recognized  that  these  striations  are  not 
exactly  straight  lines;  they  may  also  be  obliterated  by  central  pressure 
(Figs.  18-21). 

Likewise,  areas  of  hyperemia  and  anagmia  may  be  produced  by  pres- 
sure exerted  in  different  directions. 

Sometimes  the  capillary  network  in  the  mucosa  can  be  plainly  seen 
(Fig.  21). 


PHYSICAL    METHODS    OF    EXAMINATION. 


Finally,  the  lacunae  of  Morgagni,  from  6  to  12  in  number,  may  be 
observed  as  fine  longitudinal  depressions. 


Fig.  18. — Normal  urethra  in  the  center  of 
the  cavernous  portion.  Five  distinct 
folds  converging  toward  the  center;  in 
three  segments  striation  are  seen;  in  the 
other  two  they  have  been  obliterated  by 
the  pressure  of  the  tube.  The  conges- 
tion in  the  periphery  of  these  two  seg- 
ments is  due  to  the  same  cause. 


Fig.  19. — Normal  urethra.  Three  folds. 
In  the  two  segments  to  the  left  distinct 
striations  are  seen.  In  the  periphery 
of  the  right  segment  there  is  artificial 
hyperaemia. 


Fig.  20. — Normal  urethra.  Five  folds. 
In  the  three  upper  segments  there  is 
marked  striation.  In  the  other  two  the 
striations  are  indistinct  owing  to  the 
artificial  hyperaemia  at  the  periphery. 


Fig.  21. — Four  segments.  In  the  upper 
one  radiate  striations  are  seen;  in  the 
left  hyperaemia  in  the  periphery;  in  the 
right  and  lower  segments  the  vascular 
plexus  is  shown. 


Fig.   22. — Acute  gonorrhoea.      Deep  red  Fig.  23. — Granular  urethritis.    Elevations 

color  in  the  periphery  to  the  right  and  varying  in  color  from  dark  red  to  black 

below.     A  thick  streak  of  pus  passing  are'seen  near  the  center  in  the  segments 

across  the  field.  above  and  to  the  right.      In  the  seg- 

ments to  the  left  and  below  they  are 
near  the  periphery. 

If  we  now  proceed  to  a  study  of  pathologic  conditions  of  the  urethra, 
urethritis  will  be  the  first  to  interest  us.     In  the  acute  stages  urethro- 


URETHROSCOPY. 


l9 


scopy  is  contraindicated,  being  permissible  only  in  exceplional  cases 
where  doubt  exists  as  to  differential  diagnosis  between  chancroid  of  the 
urethra  and  gonorrhoea  (Fig.  22). 

Several  forms  of  chronic  urethritis  may  be  differentiated  by  means  of 
the  urethroscope,  a  fact  which  is  of  some  importance  in  regard  to  treat- 
ment. We  have  long  been  familiar  with  the  sharply  defined  circum- 
scribed areas  of  hyperemia  first  described  by  Furstenheim,  which  occur 
on  different  parts  of  the  penile  urethra,  and  also  with  the  granular 


Fig.  24. — Chronic  infiltrative  urethritis. 
Four  folds;  no  striations;  red  macula  - 
tion. 


Fig.  25. — Inflammation  of  Littre's  glands 
In  the  upper  segment  circumscribed 
redness  to  the  left.  In  the  segments  to 
the  left  and  below  hyperemia  near  the 
periphery. 


Fig  26. — Chronic  glandular  and  infiltra- 
tive urethritis.  Only  two  folds;  no 
striations.  In  the  upper  segment  a 
lacuna  of  Morgagni  having  dark  red 
edges  is  seen. 


Fig.  27. — Chronic  glandular  and  infiltra- 
tive urethritis.  The  tube  is  not  cen- 
tral but  lies  toward  the  upper  wall. 
Three  folds  are  seen.  To  the  right  and 
above  there  is  a  lacuna  of  Morgagni 
and  to  the  right  of  this  a  punctate  de- 
posit of  pus.  There  are  no  striations. 
The  tissues  are  deep  red. 


patches  of  urethritis  granulosa,  which  are  dark  red  or  black  in  color, 
resembling  those  seen  in  trachoma  (Fig.  23). 

These  forms  of  urethritis,  which  are  confined  to  the  upper  layer  of  the 
urethra,  are  closely  related  to  the  infiltrative  forms,  which  occur  both 
with  and  without  glandular  changes. 

Small-celled  infiltrations  affect  circumscribed  areas  of  the  submucosa 
to  greater  or  less  extent,  sometimes  penetrating  as  deep  as  the  corpora 


20  PHYSICAL    METHODS    OF    EXAMINATION. 

cavernosa.  A  part  of  this  infiltrate  becomes  converted  into  embry- 
onal connective  tissue,  which  in  turn  develops  into  scar  tissue 
(Neelsen,  Halle,  Wasserman,  Finger).  As  a  result  of  these  alterations 
the  appearance  of  the  surface  becomes  changed.  The  mucosa,  being 
poorly  nourished,  looks  pale,  and  in  the  worst  cases  has  a  sinewy  white 
hue;  the  epithelial  cells  die  and  become  stratified,  as  a  result  of  which 
the  lustre  of  the  mucosa  is  lost.  The  thickening  of  the  mucosa  prevents 
the  formation  of  folds,  or  at  least  greatly  reduces  their  number.     The 


Fig.  28. — Psoriasis  of  the  urethral  mucous  Fig.  29. — Mucous  ulceration.    Three  seg- 
membrane.    In  the  upper  segment  there  ments.     The  ulcer  is  above;  no  stria- 
is  a  conical  white  deposit  consisting  of  tions;  deep  redness  in  the  periphery, 
thickened  epithelium. 


Fig.  30. — Papilloma  of  the  urethra  in  the  upper  segment.     The  surrounding 
tissues  are  deep  red;  below  striations  are  seen,  to  the  right  infiltration. 

striations  are  not  so  well-marked  and  at  times  seem  entirely  wanting. 
(Fig.  24.) 

In  other  cases  these  changes  are  not  very  apparent,  glandular  affec- 
tions dominating  the  urethroscopic  picture.  We  are  indebted  to 
Oberlander  for  a  thorough  study  of  these  glandular  forms  of  urethritis. 

The  infiltrate  attacks  Littre's  glands,  some  of  which  have  their 
orifices  on  the  surface  of  the  urethra,  while  others  empty  into  the 
lacunas  of  Morgagni. 

Under  normal  conditions  Littre's  glands  cannot  be  seen,  but  when 
they  become  inflamed  they  show  as  small,  round,  dark  red  depressions 
about  as  large  as  the  head  of  a  pin,  while  Morgagni's  crypts  are  long 


URETHROSCOPY.  2! 

slit-like  openings  with  everted,  deep  red  edges.  When  pressed  upon 
by  the  tube  they  gape  so  that  the  point  of  a  small  sound  may  be  pushed 
into  them.  These  glandular  changes  are  usually  associated  with  more 
diffuse  infiltrations  of  the  submucous  tissue  (Figs.  25,  26,  27). 

Finally,  there  remains  to  be  mentioned  a  peculiar  disease  of  the 
urethral  epithelium  known  as  psoriasis  mucosa,  which  is  also  due  to 
local  nutritional  disturbances,  and  which  was  first  described  by 
Kollmann  and  Oberlander.  In  this  disease  the  surface  of  the  urethra 
is  covered  with  thick,  flat,  lustreless  white  patches,  which  are  firmly 
adherent  at  their  base  (Fig.  28). 

They  are  composed  of  thick  layers  of  dead  epithelial  cells,  both 
squamous  and  round  as  well  as  cylindrical,  which  microscopically  show 
only  a  nucleus  and  a  mass  of  colorless  detritus. 

All  of  these  infiltrative  forms  except  the  last  are  associated  with  some 
narrowing  of  the  urethra,  although  a  marked  degree  of  contraction  is 
not  present.  They  are  the  strictures  of  large  caliber  described  by 
Otis. 

In  true  stricture  urethroscopy  has  neither  diagnostic  nor  therapeutic 
value,  because  the  constrictions  can  be  better  felt  than  seen;  moreover, 
they  can  be  treated  better  without  the  endoscope  than  with  it. 

Ulcerations  and  tumors,  on  the  other  hand,  offer  a  very  satisfactory 
field  for  urethroscopy. 

To  the  first  class  belong  simple  erosions,  hard  and  soft  chancres, 
tuberculous  ulcers,  and  degenerated  gummata.  They  are  easily  recog- 
nized, as  they  always  produce  loss  of  substance.  A  true  ulcer  is  always 
deeper  than  the  surrounding  tissue.  Erosions  result  from  simple  or 
gonorrhceal  inflammation  or  from  the  passage  of  instruments,  and 
may  occur  in  any  part  of  the  urethra.  They  are  small  spots  about  the 
size  of  a  millet-seed  and  are  not  covered  with  epithelium. 

Soft  and  hard  chancres  are  usually  at  or  near  the  cutaneous  orifice, 
although  the  first  also  occur  in  the  deeper  portions  of  the  urethra.  The 
sense  of  sight  does  not  enable  us  to  determine  whether  a  chancre  is  soft  or 
hard,  so  conclusions  as  to  its  nature  must  be  drawn  from  the  accompany- 
ing circumstances  of  the  case.  The  area  surrounding  a  soft  chancre  is 
usually  very  red  (Fig.  29).  In  hard  sores  the  infiltration  can  be  felt 
from  without. 

If  tuberculous  ulcers  are  present  or  suspected,  the  urethroscope  should 
not  be  used,  as  it  may  cause  dissemination  of  the  tubercles.  Tubercu- 
losis of  the  urethra  gives  rise  to  tight  strictures  which  withstand  all 


2  2  PHYSICAL    METHODS    OF    EXAMINATION. 

forms  of  treatment  except  operation.  On  the  surface  of  the  mucous 
membrane  nodular  granulations  and  ulcers  are  seen. 

The  tumors  affecting  the  urethra  are  polypi,  papillomata,  and  carci- 
nomata. 

Polypi  are  very  rare ;  they  are  pale,  pedunculated  little  growths  which 
can  be  plainly  seen  and  easily  recognized. 

Papillomata  are  more  common.  They  invade  all  parts  of  the  urethra, 
but  have  a  predilection  for  the  colliculus  seminalis.  They  are  almost 
always  multiple.  If  they  are  discovered  in  the  anterior  urethra  the  pos- 
terior urethra  must  be  examined  with  the  urethroscope.  (Fig.  30.) 

Carcinoma  of  the  urethra  is  very  rare.  It  produces  firm,  incurable 
strictures,  which  can  always  be  palpated  from  without  and  therefore 
require  no  urethroscopic  inspection. 

3.     CYSTOSCOPY. 

Cystoscopy  is  a  term  applied  to  the  method  of  examining  the  bladder 
visually  by  means  of  an  instrument  introduced  through  the  urethra. 
The  efforts  made  to  attain  this  object  date  from  the  beginning  of  the  last 
century.  Segalas,  Fischer,  Desormeaux,  Cruise,  Fiirstenheim,  Stein, 
and  Griinfeld  followed  the  German  physician  Bozzine,  of  Frankfurt-am- 
Main  (1807)  in  an  attempt  to  construct  cystoscopic  instruments.  With 
the  exceptions  of  some  unimportant  details  their  methods  were  the  same. 
They  passed  a  tube  through  the  urethra  into  the  bladder  and  reflected 
light  into  that  viscus  from  without  by  means  of  a  mirror.  Excluding 
Bruck's  diaphanoscopic  method,  which  was  never  made  practical  use  of, 
the  attempts  of  all  these  investigators  may  be  criticised  as  being  totally 
inadequate  for  the  purpose  for  which  they  were  intended.  Their  illum- 
ination was  defective  and,  moreover,  only  a  very  small  area  of  the  bladder 
wall,  scarcely  larger  than  the  lumen  of  the  tube  introduced,  could  be 
seen  at  one  time. 

It  was  Nitze  who  in  1877  first  fully  recognized  this  defect  and  intro- 
duced two  new  principles  in  the  examination  of  the  interior  of  the 
bladder,  as  a  result  of  which  cystoscopy  became  a  serviceable  method. 

He  established  the  fundamental  principle  that  illumination  of  a  hollow 
viscus  connected  with  the  exterior  of  the  body  by  a  long  narrow  canal  is 
possible  only  when  the  source  of  light  is  carried  into  the  viscus  itself. 
Furthermore,  he  maintained  that  even  if  this  requisite  be  fulfilled,  satis- 
factory inspection  of  the  bladder  could  not  be  made  unless  a  consider- 
able  portion  of  its  surface  could  be  seen  at  one  view.     If  both  con- 


CYSTOSCOPY.  23 

ditions  could  be  fulfilled,  then  by  moving  the  instrument  about  the 
whole  surface  of  the  bladder  could  be  examined. 

Both  were  realized  when  it  became  possible  to  carry  an  electric  light 
into  the  bladder  without  causing  pain  or  injury,  and  to  construct  an 
optical  instrument  magnifying  the  field  of  vision. 

The  electric  light  was  devised  by  Nitze  and  a  Viennese  instrument 
maker  named  Leiter.  It  was  supplied  by  a  platinum  wire  heated  to 
a  white  heat.  This  wire  was  covered  with  glass,  the  two  together 
being  contained  in  an  irrigator  which  permitted  a  current  of  cold 
water  to  flow  around  them  while  the  wire  was  burning,  and  thus  pre- 
vent injury  of  the  bladder.  It  is  the  same  method  which  Bruck 
applied  to  his  diaphanoscope  illumination.  To  Nitze  belongs  the 
merit  of  rendering  Brack's  method  of  illumination  practical  for  ex- 
amining the  bladder.  The  'optical  apparatus,  somewhat  similar  to 
a  telescope,  was  made  by  the  optician  Beneche  in  conformity  with  a 
suggestion  of  Nitze's.  The  irrigating  apparatus  around  the  platinum 
wire  rendered  the  instrument  so  complicated  and  so  uncertain  of  appli- 
cation that  it  could  be  used  only  with  difficulty,  or  not  at  all,  and  for  this 
reason  cystoscopy  did  not  gain  entrance  to  the  practice  of  urologists  and 
surgeons. 

When  the  Edison  lamp  succeeded  the  platinum  wire  a  change  was 
wrought  at  one  stroke.  On  the  point  of  the  catheter-like  instrument 
where  the  platinum  wire  formerly  was  placed,  an  Edison  lamp  was  at- 
tached and  connected  with  a  battery  or  accumulator  which  furnished  a 
beautiful  bright  light  without  producing  much  heat.  Thus  an  unser- 
viceable instrument  was  converted  into  a  useful  one. 

The  irrigator  was  discarded  as  superfluous;  the  instrument,  as  easy 
of  introduction  as  any  silver  catheter,  worked  well  and  safely.  The 
change  was  an  important  one  for  cystoscopy.  Since  it  was  instituted 
the  method  has  won  universal  recognition  and  become  the  common 
property  of  the  profession.  To  this  change  are  due  the  surprisingly 
favorable  results  obtained  as  well  as  the  wide  propagation  the  method 
has  undergone. 

This  improvement  in  the  instrument  was  made  public  at  about  the 
same  time  by  Nitze  and  Dittel,  the  latter  being  represented  by  Dr.  Bren- 
ner at  the  Surgical  Congress  at  Berlin  in  the  year  1879. 

In  order  to  understand  the  cystoscope  and  cystoscopy  a  thorough 
knowledge  of  the  second  principle  enunciated  by  Nitze,  namely,  in- 
crease in  the  apparent  dimensions  of  the  field  of  vision  by  means  of 


24  PHYSICAL    METHODS    OF    EXAMINATION. 

an  optical  contrivance  is  indispensible.  This  device  consists  of  a  tube 
(R  Fig.  31)  having  an  objective  (O)  at  its  vesical  end  and  an  eyepiece 
(L)  at  its  external  end.  The  objective  consists  of  one  or  more  lenses 
which  throw  a  small  inverted  image  (B)  of  the  opposite  object  (B'),  pro- 
portionate in  size  to  its  index  of  refraction,  into  the  interior  of  the  tube, 
where  it  lies  close  behind  the  objective  and  is  rein  verted  by  a  lens  (U) 
in  the  middle  of  the  tube  and  then  transferred  to  its  outer  end  against 
the  eyepiece  (B"),  which  acts  as  a  magnifying  glass  and  enlarges  the 
upright  image.  (Fig.  31.) 

When  one  looks  through  the  eyepiece  he  sees  an  image  of  the  ob- 
ject lying  opposite,  varying  in  size  according  to  the  distance  at  which 
it  is  removed.  In  the  words  of  Nitze,  "one  sees  in  the  inner  field  of 
vision  that  part  of  the  opposite  object  which  lies  within  an  imaginary 
cone  whose  axis  is  perpendicular  to  the  free  surface  of  the  objective." 

R  ___ 

in 


B 


0  B'  U  B"  L 


Fig.  31. — Optical  Apparatus  of  the  Cvstosocpe. 


The  size  of  this  cone  varies;  the  better  the  objective  the  larger  the 
cone.  In  the  best  instruments  which  I  have  seen  the  divergence  of  the 
cone  was  from  80  to  90  degrees.  The  size  of  the  opposite  surface 
(bladder)  as  seen  in  the  inner  field  of  vision,  which  itself  remains  con- 
stant in  size,  is  increased  as  the  objective  is  moved  away,  and  there- 
fore the  details  of  the  picture  become  less  distinct;  it  is  decreased  in 
size  as  the  objective  is  carried  toward  the  surface,  thus  making  the 
details  larger  and  more  distinct.  The  natural  size  of  an  object  is  seen 
at  a  distance  of  about  2  cm.  (f  of  an  inch).  If  the  instrument  be 
carried  nearer  less  is  seen,  but  the  image  becomes  plainer  and  larger, 
whereas  if  the  objective  be  moved  away  more  is  seen,  but  the  picture 
is  less  distinct. 

From  these  statements  two  things  bearing  on  practical  cystoscopy 
may  be  learned ;  first,  that  as  errors  may  result  from  increasing  or  dimin- 
ishing the  size  of  an  object  beyond  its  natural  dimensions  one  should 
form  an  opinion  concerning  the  size  of  the  object  observed  by  varying 
the  distance  of  the  objective;  and  second,  that  objects  such  as  organs  of 
the  body  will  appear  distorted  because  their  more  distant  portions  will 
be  diminished  in  size  while  their  nearer  parts  will  be  magnified.     If  the 


CYSTOSCOPY. 


25 


examiner  knows  and  considers  these  facts  he  will  be  able  by  a  little  prac- 
tice to  eliminate  the  element  of  distortion  in  the  image  and  judge  cor- 
rectly as  to  its  size.  If  we  turn  our  attention  to  a  description  of  the 
cystoscope  itself,  of  which  there  are  many,  it  may  be  said  that  the  one 


Fig.  32. — Nitze's  Cystoscope  I. 


Fig.  34. — Nitze's  Cystoscope  II. 


which  is  almost  universally  used  and  which  suffices  for  nearly  all  cases 
consists  of  a  sound  having  a  Mercier  curve  and  a  shaft  from  22  to  25  cm. 
(9  to  10  inches)  in  length.  (Fig.  32.) 
On  the  tip  of  the  sound  is  an  Edison  lamp  (E)  in  a  setting  which  is 


26  PHYSICAL    METHODS    OF    EXAMINATION. 

screwed  onto  the  shaft  (F).  Under  the  surface  of  the  lamp  is  a  fine 
insulated  platinum  wire  which  becomes  connected  with  the  insulated 
conducting  wire  of  the  shaft  when  the  lamp  is  attached.  (Fig.  33.) 

In  the  concavity  of  the  angle  formed  by  the  junction  of  the  shaft 
with  the  beak  of  the  instrument  there  is  a  right-angled  prism 
whose  hypotenuse  lies  in  the  elongation  of  the  back,  while  the 
base  falls  perpendicular  to  the  long  axis  of  the  shaft  and  the  up- 
right runs  parallel  with  the  shaft.  (Fig.  33  P.)  The  surface  at  the 
hypotenuse  of  this  prism  is  silvered,  so  that  when  one  looks  through  the 
funnel  at  the  external  end  of  the  instrument  he  sees  the  objects  opposite 
the  free  cathetus  of  the  prism.  The  optical  apparatus  previously  de- 
scribed is  placed  close  to  this  prism,  so  that  one  really  sees  only  as  much 
of  the  opposite  bladder  wall  "as  lies  within  the  envelope  of  an 
imaginary  cone  whose  axis  is  perpendicular  to  the  free  surface  of  the 
prism."     (Nitze.) 

The  second  cystoscope  (Fig.  34),  which  is  especially  adapted 
for  examining  the  fundus  of  the  bladder,  but  which  it  is  only  rarely 
necessary  to  use,  has  its  prism  (P)  placed  at  the  convexity  of  the  angle. 
At  the  junction  of  the  shaft  and  beak  a  mirror  (h)  is  set  and  the  opti- 
cal contrivance  so  placed  that  when  one  looks  into  the  instrument  he 
sees  that  part  of  the  bladder  which  lies  opposite  the  free  surface  of 
the  prism  (P). 

Nitze  has  also  invented  an  instrument  which  is  called  the  irrigating 
cystoscope.  The  object  of  this  instrument  is  to  irrigate  during  exam- 
ination whenever  the  interior  of  the  bladder  is  made  turbid  by  pus  or 
blood,  and  so  restore  its  transparency.  In  construction  this  instrument 
is  essentially  the  same  as  the  one  first  described.  (Fig.  35.) 

Underneath  the  prism  are  several  small  openings  which  communicate 
with  a  canal  extending  down  the  end  of  the  funnel.  On  the  side  of  the 
instrument  there  is  a  larger  aperture  which  also  communicates  with  a 
canal  running  the  whole  length  of  the  instrument.  These  canals  term- 
inate in  two  processes  (B)  and  are  opened  and  closed  by  stop-cocks  (C). 
Thin  rubber  tubes  are  attached  to  these  processes.  During  examina- 
tion an  assistant  injects  clearfluid  (Hydrarg.  oxycyanat  solution  T-5000) 
through  the  tap  leading  to  the  small  apertures  beneath  the  prism. 
In  this  way  the  prism  is  irrigated  and  freed  from  blood  or  mucus.  At  the 
same  time  the  other  stop-cock  is  opened  and  the  turbid  fluid  allowed  to 
run  out.  This  arrangement,  concerning  the  importance  of  which  we 
shall  have  something  further  to  say,  gives  a  more  limited  field  of  vision, 


CYSTOSCOPY. 


27 


though  withal  a  clearer  one,  than  other  instruments.     The  instrument 
itself  is  somewhat  larger,  being  about  24  to  25  French. 


pf 


<  m 

Fig-  35- — Nitzc's  irrigating  Fig.  36. — Boisseau  du  Rocher's 

cystoscope.  megaloscope. 

This  irrigating  cystoscope  has  been  improved  upon,  being  made  with 
only  one  canal,  which  is  larger  than  either  of  those  in  the  original  instru- 


28  PHYSICAL    METHODS    OF    EXAMINATION. 

ment  and  therefore  does  not  become  so  easily  clogged  as  did  the  finer 
ones.  In  using  the  new  instrument  it  is  necessary  to  irrigate  and  allow 
the  fluid  to  run  out  as  often  as  the  picture  becomes  blurred.  The  size  of 
this  instrument  is  22  French. 

Different  in  construction  from  any  of  these  instruments  is  one  called 
the  megaloscope,  which  was  invented  by  Boisscau  du  Rocher  (Fig.  36). 
It  has  a  lamp  (L)  at  its  end  on  the  convex  side,  and  the  optical  apparatus 
is  introduced  separately,  a  special  opening  (O)  being  provided  for  it  at 
the  obtuse  angle  formed  by  the  junction  of  the  shaft  with  the  shortly 
curved  beak.  This  opening,  which  is  closed  by  an  obturator  during  the 
introduction  of  the  instrument,  is  used  for  washing  out  and  filhng  the 
bladder.  In  addition  to  it  there  is  a  special  double  irrigating  apparatus 
(CC  and  MM';  which  serves  to  keep  the  contents  of  the  bladder  free 
from  turbidity  during  the  introduction  of  the  optical  apparatus,  and 
which  can  also  be  used  for  inserting  ureteral  catheters.  (Fig.  36.) 

The  megaloscope  differs  from  the  cystoscope  in  that  it  has  no  prism, 
that  portion  of  the  bladder  wall  which  lies  opposite  the  optical  apparatus 
being  brought  into  view.  The  instrument  is  awkward  and  unsuitable 
for  use. 

The  late  Dr.  Giiterbock  invented  a  cystoscope  which  is  very  useful  in 
many  cases.  It  differs  from  all  cystoscopes  previously  constructed  in 
that  the  cystoscope  proper  consists  of  an  inner  tube  (Fig.  37  b.)  which 
is  passed  into  the  bladder  through  another  catheter-like  instrument  (Fig. 
37a).  For  the  lamp  (L)  and  prism  (P)  of  the  cystoscope-tube  there  are 
corresponding  notches  (F  and  B)  in  the  outer  tube.  When  using  this 
instrument  it  is  not  necessary  to  wash  the  bladder  out  with  another 
catheter,  for  it  can  be  irrigated  through  the  outer  tube  (Fig.  37a.)  and 
the  inner  tube  introduced  as  soon  as  the  bladder  has  been  cleansed 
and  filled  with  water. 

Winter  has  prepared  a  cystoscope  for  the  female  bladder  which  is 
thicker  and  shorter  than  those  used  for  men.  Otherwise  it  does  not 
differ  from  the  ordinary  instruments.  As  the  male  cystoscopes  give  a 
good  view  of  the  female  bladder  Winter's  instrument  may  be  dis- 
pensed with. 

For  the  purpose  of  fixing  pathologic  conditions  of  the  bladder,  Xitze, 
and  after  him  the  instrument  maker  W.  A.  Hirschmann,  of  Berlin,  con- 
structed a  photographic  cystoscope  by  means  of  which  very  good 
pictures  of  the  interior  of  the  bladder  can  be  taken.  The  principle 
of  this  instrument  is.  that  the  image  in  the  interior  of  the  tube  is 


CYSTOSCOPY.  29 

brought  to   the   ocular   end  and  photographed  by  a  camera  which  is 


u 


— 


O 
— 
PL, 


be 


placed  there.     In  Nitze's  instrument  the  camera  is  round  and  eccentric 
(Fig.  38),  while  in  Hirschmann's  it  is  angular  (Fig.  39).      The  latter  is 


3° 


PHYSICAL    METHODS    OF    EXAMINATION. 


easier  to  handle  and  also  permits  of  an  exceptionally  rapid  insertion 
and  withdrawal  of  the  plates  (Fig.  39). 


Many  cystoscopes  for  catheterizing  the  ureters  have  been  devised. 
For  the  female  bladder  Brenner's,  which  was  one  of  the  first,  fulfills  all 


CYSTOSCOPY. 


31 


requisites.  It  has  a  tunnel  on  its  convex  side  through  which  the  ureteral 
catheter  is  passed;  the  lamp  is  also  on  the  convex  side,  so  that  one  looks 
straight  through  the  tube  into  the  bladder  (Fig.  40). 


Fig.  41. — Albarran's  Ureteral  Cystoscope. 

H 


D 


M 


I) 


I) 


Fig.  42  — Casper's  Ureteral  Cystoscope. 

An  instrument  intended  for  catheterizing  the  ureters  must  be  appli- 
cable to  both  sexes.  It  must  fulfill  the  following  conditions:  the 
catheter  must  have  a  variable  curve  and  must  remain  in  the  ureter 
when  the  metal  instrument  is  withdrawn ;  it  must  be  so  constructed  as 


32 


PHYSICAL    METHODS    OF    EXAMINATION. 


to   permit   the   introduction  of  a  catheter  into  both  ureters  at  a  single 
sitting.     These   requirements   are   nearly   met   in   Albarran's    ureter- 


gjwimimmimnii* <fc- 


Fig.  43. — Belfield  diagnostic  cystoscope.     Cold  lamp — water  or  air  dilatation — direct  vision 


Fig.  44. — The  Eransford  Lewis  operative  cystoscope  and  accessories;  ureter  forceps, 

dilators,  scissors,  etc. 

cystoscope  (Fig.  41),  and  are  entirely  supplied  by  my  new  ureter-cysto- 
scope,  the  cut  of  which  (Fig.  42)  offers  sufficient  explanation. 

Finally  the  instruments  intended  for  use  in  endovesical  operations 
remain  to  be  mentioned.  Nitze  devised  a  good  snare  and  galvano- 
cautery  and  Hirschmann  manufactures  one  for  me  which  serves  the 
same  purpose  and  has  in  addition  cystoscopic  forceps. 


CYSTOSCOPY. 


33 


N 


/ 


C5 


^, 


pq 


^iiiiiiMi^^S 


R 


L 


pIG    45 — The  Bransford  Lewis  Universal  Cystoscope. — Latest  model. 


[Among  the  principal  American  cystoscopes  may  be  mentioned  the 
instruments  of  Belfield,  Bransford  Lewis,  Otis,  Wintield  Ayres, 
F.  Tilden  Brown,  and  Bierhoff. 

Belfield's  instrument  (Fig.  43)  is  for  air  or  water-distention,  with  or 

3 


34  PHYSICAL    METHODS    OF    EXAMINATION. 

without  a  lens  system,  and  is  the  first  air-distention  cystoscope  ever 
devised. 

The  Bransford  Lewis  operative  cystoscope  (Fig.  44)  permits,  in 
addition  to  intravesical  operative  work,  intra-ureteral  manipulations 
for  the  removal  of  calculi  and  the  dilatation  of  strictures,  as  well  as 
-irrigation  of  the  pelvis  of  the  kidney  and  the  application  of  topical 
remedies  to  the  ureter.  By  its  use  deviations  of  the  ureter  may  also  be 
determined.  Thus  it  is  seen  that  this  instrument  opens  an  entirely 
new  field  in  ureteral  surgery.  The  results  thus  far  obtained  have 
been  very  gratifying. 

The  universal  cystoscope  recently  devised  by  Dr.  Lewis  is  a  most 
ingenious  instrument.   (Fig.  45). 

With  one  sheath  and  three  periscopes,  this  cystoscope  embodies  the 
following  several  purposes:  Through  water-medium,  furnishes  right- 
angle  view,  retrospective  view  (for  inspection  of  the  prostate),  and 
direct  forward  view  for  observing  the  summit  and  upper  part  of  the 
posterior  wall;  and,  in  connection  with  the  latter,  permits  catheteriza- 
tion of  both  ureters  at  once.  With  air-medium  and  the  ocular  window 
it  also  permits  double  ureter-catheterization.  The  sheath  is  simple 
and  free  of  impediments.  The  cold  lamp  in  the  beak  is  set  base 
upwards  and  bulb  downwards,  so  as  to  throw  the  light  in  the  direction 
desired;  and,  through  fenestra  on  both  concave  and  convex  sides  of 
the  beak,  throws  its  rays  in  both  of  these  directions.  It  is  well  pro- 
tected, at  the  same  time,  by  both  metal  and  glass  chamber,  the  latter 
obviating  the  necessity  of  a  metal  bridge  across  the  heel  of  the  beak, 
which  would  cast  a  shadow  from  that  point. 

A  new  arrangement  of  catheter-tubes  and  lenses  for  the  direct-new 
periscope  permits  full-sized  lenses,  notwithstanding  the  presence  of  the 
tubes,  thus  conserving  light  and  enlarging  the  field  of  vision.  Vesical 
irrigation  can  be  rapidly  accomplished  through  the  sheath  of  the  instru- 
ment. The  outside  caliber  is  23  French.  The  periscopes  are  quickly 
interchangeable  without  removal  of  the  instrument  from  the  bladder.* 

The  late  W.  K.  Otis,  by  substituting  a  hemispherical  lens  for  the  prism, 
has  produced  a  cystoscope  having  a  field  four  times  as  large  as  that 
of  any  other  rectangular  instrument.  The  lamp  in  this  instrument 
emits  but  little  heat.  It  is  set  at  the  vesical  end  of  the  sheath,  one 
pole  being  on  the  metal  of  the  shaft,  the  other  being  supplied  by  an 

*  A  recent  improvement  in  this  instrument  permits  catheterization  of  the  ureters 
by  the  indirect  as  well  as  the  direct  method. 


CYSTOSCOPY. 


35 


especially  insulated  wire,  which  does  not  encroach  upon  the  internal 
caliber  of  the  shaft  and  permits  the  use  of  a  larger  telescope  than  has 
been  heretofore  employed,  thereby  affording  a  greater  amount  of  light 
and  consequently  a  brighter  image.   (Figs.  46  and  47.)] 

Winfield  Ayres'  cystoscope  combines  direct  observation  of  the 
bladder,  giving  a  very  clear  view  of  the  trigone,  floor  and  posterior 
wall,  and  indirect  observation,  giving  a  view  of  the  summit,  side-walls, 
trigone  and  floor.  Also  a  retrograde  observation,  giving  a  view  of  the 
vesical  neck. 


Fig.  46. — Triangular  lens 
[of  the  Otis  cystoscope. 


Fig.  47. — A,  field  of  vision  given  by  the  Otis  cystoscope,  B 
field  of  vision  given  by  Nitze's  cystoscope. 

Bilateral  catheterization  of  the  ureters  may  be  done  with  this 
cystoscope  by  the  direct  method.  The  catheter  introducing  tubes 
are  only  one  inch  in  length  and  are  therefore  easily  kept  clean  and  dry. 
Attached  to  the  under  surface  of  the  direct  telescope  is  a  fin  which 
divides  the  sheath  into  two  catheter  chambers.  This  arrangement 
makes  it  possible  to  remove  the  cystoscope  after  the  catheters  have 
been  inserted  in  the  ureters  without  disturbing  their  position.  Also 
the  catheter  chambers  are  easily  kept  clean  and  sterile.  The  cysto- 
scope carries  two  No.  6|  catheters  easily.     (Fig.  48.) 

F.  Tilden  Brown's  composite  cystoscope,  constructed  for  the  male 


36  PHYSICAL    METHODS    OF    EXAMINATION. 

and  female  bladder,  may  be  used  with  either  water-  or  air-distent  ion. 
It  consists  of  a  sheath  with  an  obturator  and  lock  nut  and  also  two 
stopcocks  for  irrigating.  Upon  withdrawal  of  the  obturator,  the 
telescope,  fitted  with  two  catheter  channels,  is  introduced  and  securely 
locked,  thus  permitting  a  direct  view  of  the  bladder  wall.  Either 
single  or  double  catheterization  of  the  ureters  can  be  made  with  this 
instrument.  The  catheters  protrude  from  the  distal  end  in  a  straight 
position,  and  therefore  a  special  guide  is  unnecessary.  Fenestration 
of  the  catheter  canals  makes  it  easy  to  remove  the  cystoscope  and 
leave  the  catheters  in  the  ureters. 

Because  of  the  independent  and  open  sheath  employed  in  this 
instrument,  auxiliary  telescopic  tubes  can  be  utilized,  being  readily 


3 

Fig.  48. — Winfield  Ayres'  cystoscope. 

interchangeable  once  the  sheath  has  been  passed  into  the  bladder. 
For  example,  there  is  a  telescope  giving  a  retrograde  view  and  one 
with  a  single  large  catheter  canal  for  carrying  a  dilatation  catheter  or 
permitting  the  use  of  forceps  for  grasping  calculi,  foreign  bodies  or 
tumors.  Through  the  irrigating  cocks  the  bladder  may  be  washed 
or  the  distending  medium  changed  while  any  of  the  tubes  are  in  the 
sheath  or  before  one  is  introduced.     (Fig.  49.) 

Bierhoff's  double  catheterizing  and  irrigating  cystoscope  consists 
of  a  plain  examining  cystoscope  (No.  16  French  scale),  with  beak  and 
lamp  removable  for  introducing  into  an  outer  sheath,  which  is  furn- 
ished with  a  double  channel  for  ureter  catheters.  This  double 
channel  permits  two  No.  6  catheters  to  be  introduced  simultaneously. 

A  catheter  guiding  attachment  is  fitted  to  the  distal  end  of  the 
instrument  near  the  optical  part,  controlled  by  a  lever  at  the  proximal 
end,  which  raises  or  lowers  the  tip  of  the  catheter  to  guide  it  into  the 


CYSTOSCOPY. 


37 


ureter.  The  principal  advantage  of  this  instrument  is  that,  in  cases 
in  which  it  is  desirable  to  leave  catheters  in  the  ureters  for  a  certain 
length  of  time,  it  can  be  withdrawn  without  causing  the  catheters  to 


Fig.  49. — F.  Tilden  Brown's  composite  cystoscope.  1908  model.  S..  common  sheath 
for  various  telescopes;  O.,  obturator;  I.  C,  indirect  vision  (double  catheter)  telescope; 
I.E.,  indirect  vision  examining  telescope;  D.  E..  direct  vision  examining  telescope; 
D.C.,  direct  vision  (double  cathetenzing)  telescope;  O.Y.  C.  oblique  vision  (double 
catheterizing  telescope;  C.  P.  O.,  correcting  or  compensating  prism  ocular,  interchange- 
able with  the  ocular  on  I.  C.  and  I.  E. 


become  twisted.     When  removing  the  cystoscope,  it  is  not  necessary 
to  turn    the  entire  instrument,  but  the  telescope  only,  as  this  can  be 


38  PHYSICAL    METHODS    OF    EXAMINATION. 

fully  revolved  within  the  outer  sheath;  the  size  of  the  instrument  is 
No.  23  French  scale.  The  above  can  also  be  used  as  a  plain  examin- 
ing cystoscope  by  removing  the  outer  sheath,  and  with  the  latter,  as 
an  irrigating  cystoscope,  by  using  the  catheter  channels  for  the 
injection  of  water. 

A  further  advantage  of  this  instrument  is  that,  the  catheter- 
carrying  part  thereof,  being  easily  removable,  may  be  sterilized  by 
boiling.     (Fig.  50.)] 

The  technic  of  cystoscopy  is  very  simple.  In  order  for  it  to  be  suc- 
cessful three  conditions  must  be  fulfilled: 

1.  The  urethra  must  freely  admit  the  instrument ;  therefore  strictures 
must  not  be  present.  The  cystoscope  must  pass  so  easily  that  no 
bleeding  is  produced,  for  if  haemorrhage  occur  the  prism  will  be  soiled 


* J3bfcr; 


Fig.  50. — Bierhoff's  cystoscope. 

and  the  view  of  the  bladder  will  become  obscure.  The  introduction 
of  the  instrument  presents  no  difficulties,  being  the  same  as  that  of 
any  metal  catheter,  except  that  in  order  to  pass  over  the  internal 
sphincter,  the  instrument,  owing  to  its  short  beak,  must  be  depressed 
more  than  a  catheter  having  a  greater  curve. 

2.  The  bladder- walls  lie  in  apposition  when  the  viscus  is  empty  and 
therefore  it  must  be  distended  so  that  a  good  view  of  all  its  parts  can  be 
obtained  and  the  beak  of  the  cystoscope  freely  moved  about  in  the 
vesical  cavity.  A  contracted  bladder  (concentric  hypertrophy),  for 
example,  with  considerable  diminution  in  capacity  makes  the  perform- 
ance of  cystoscopy  impossible. 

3.  The  bladder  must  be  filled  with  a  clear  medium  so  that  its  walls  can 
be  plainly  seen. 

Distention  of  the  bladder  with  a  transparent  medium  is  secured  by 
injecting  into  it  a  t  :  5000  solution  of  oxycyanate  of  mercury  by  means  of 
a  catheter  and  hand-syringe  or  irrigator.     From  100  to  150  cm.  [3  to  5 


cystoscopy.  39 

fluid  ounces]  are  injected  and  allowed  to  run  out  again  until  the  fluid  re- 
turns absolutely  clear  and  transparent.  Then  from  150  to  200  cc.  [5  to  7 
ounces]  are  injected,  the  catheter  withdrawn,  and  the  cystoscope,  care- 
fully disinfected  and  smeared  with  "  Katheterpurin "  (see  page  50) 
introduced.  Oil  and  vaseline  cannot  be  used  because  they  soil  the 
prism. 

In  sensitive  patients  the  urethra  may  be  cocainized  by  injecting  from 
5  to  8t  grammes  [1  to  1 J  fluid  drachms]  of  a  2  per  cent  cocaine  solution, 
and  having  the  patient  hold  it  for  three  minutes.  Cocainization  of  the 
bladder  is  inadmissible  an  account  of  the  danger  of  poisoning.  Before 
introducing  the  cystoscope  it  is  well  to  test  the  strength  of  the  current 
which  lights  the  lamp.  During  its  introduction  the  current  must  be 
turned  off. 

We  now  come  to  a  short  consideration  of  what  can  be  accomplished 
with  cystoscopy,  and  in  order  that  pathologic  conditions  may  be 
better  understood  we  will  first  describe  the  pictures  presented  by  the 
normal  bladder. 

As  to  its  color,  the  normal  mucous  membrane  of  the  bladder  varies 
from  bright  yellow  to  pink;  it  is  only  at  the  base  that  a  somewhat  redder 
hue  is  seen.  The  longer  an  examination  is  continued  the  greater  the 
quantity  of  urine  poured  out  from  the  ureters  into  the  bladder,  and  con- 
sequently the  color  becomes  redder  because  of  the  constantly  increas- 
ing yellowness  of  the  medium.  Likewise  as  the  brightness  of  the 
light  diminishes,  the  tone  of  color  assumes  a  redder  tint,  so  that  it  be- 
hooves us  always  to  examine  with  a  bright  white  light. 

Besides  the  color  the  delicate  ramifying  blood  vessels,  which  are 
especially  well  developed  in  the  fundus,  attract  attention.  They  form 
pictures  similar  to  those  seen  in  the  fundus  of  the  eye  with  the  ophthal- 
moscope (Figs.  51,  52,  53). 

On  the  bladder- walls,  especially  on  the  superior  and  lateral  portions, 
small  longitudinal  and  transverse  protruding  arches  are  seen,  which 
are  composed  of  bundles  of  muscular  fibres  given  off  from  the  detrusor 
vesicae  (Fig.  54).  On  the  fundus  they  are  not  so  distinct  because  of 
their  firm  attachment  to  the  neighboring  parts. 

If  these  bands  become  firm  and  form  unyielding  columns,  wchave  the 
so-called  trabecular  bladder  (vessie  a  colonnes),  a  condition  which 
always  results  from  increased  work  put  on  the  detrusor,  as  for  instance, 
that  caused  by  stricture  or  hypertrophy  of  the  prostate.  (Figs.  55  and  56). 

Between  these  trabecular  are  often  found  deep  pocket-like  recesses, 


4° 


PHYSICAL    METHODS    OF    EXAMINATION. 


the    so-called  diverticula,  which  look  like  deep  excavations   in   the 
bladder-wall. 

If  the  instrument  be  drawn  back  from  the  middle  of  the  vesical 
cavity,  a  portion  of  the  circular  field  of  vision  representing  the  bladder- 
wall  will  disappear.  This  will  be  taken  from  the  semilunar  shadow 
corresponding  to  the  internal  orifice  of  the  urethra.     This  shadow, 


Fig  57- 


Fig.  58. 


Fig-  59- 


which  has  an  upward  incurvation,  is  due  to  the  fact  that  a  part  of  the 
prism  is  covered  by  the  sphincter  vesicae  muscle.  Under  normal  con- 
ditions this  shadow  or  fold  is  smooth,  fine,  and  partly  transparent. 
(Figs-  57.  58,  59,  60). 

Any   arched  prominences  which  may  be  present  at  the  sphincter, 
as  for  example,  such  as  occur  in  prostatic  hypertrophy,  are  character- 


CYSTOSCOPY. 


41 


ized  by  protuberances  or  irregularities  of  the  sphintcric  fold,  together 
with  darkened  areas  here  and  there  (Fig.  61).  If  the  beak  of  the 
cystoscope  be  carried  downwards,  the  base  of  the  bladder  is  brought 
into  view;  and  if  it  be  pushed  a  little  backwards  and  turned  a  little  to 
the  side,  the  ureteral  elevations  are  seen,  although  they  are  not  always 
equally  well-marked.     They  generally  resemble  the  frustum  of  a  cone 


Fig.  66. 


Fig.  67. 


Fig.  68. 


in  shape,  and  on  their  summit  have  the  slit-like  opening  of  the  ureters. 
(Figs.  62,  63,  64,  65). 

If  one  watches  these  fissures  for  a  short  time,  they  will  be  seen  to  swell 
up  suddenly,  or  make  a  convulsive  movement,  and  at  the  same  time  an 
eddy  will  be  observed  in  the  vesical  fluid.  These  phenomena  are 
caused  by  the  discharge  of  urine,  which  occurs  at  greatly  varying 
intervals. 

Furthermore, in  cases  of  inflammation,  ulceration,  tumors,  stones, 


42 


PHYSICAL    METHODS    OF    EXAMINATION. 


and  foreign  bodies  and  also  in  certain  renal  affections,  the  cystoscope 
shows  striking  pictures  which  are  of  great  diagnostic  value. 

The  pictures  of  cystitis  are  exceptionally  varied.  In  the  acute 
forms,  in  which  cystoscopy  should  be  avoided  if  possible,  the  base  of 
the  bladder,  especially  around  the  sphincter,  is  seen  to  be  deep  red. 
Upon  closer  inspection  it  is  seen  that  this  redness  is  due  to  a  well-devel- 


Fig.  69. 


Fig  75- 


Fig.  70. 


Fig.  71. 


Fig-  76. 


Fig-  77- 


oped,  fine  vascular  network  {cystitis  colli  gonnorrhoica  acuta  et  subacula). 
In  the  chronic  forms,  which  correspond  to  the  different  varieties  of 
vesical  catarrh,  puffiness,  softening  and  redness  of  the  mucous  mem- 
brane, together  with  the  secretion  present  are  the  conditions  which 
meet  the  eye.  The  mucous  membrane  has  a  spongy  appearance,  looks 
velvety,  and  sometimes  presents  swellings  so  thick  that  they  may  be 
mistaken  for  tumors.     A  distinct  vascular  network  is  no  longer  per- 


CYSTOSCOPY. 


43 


ceived,  the  surface  of  the  bladder  looking  dull  and  cloudy.  The  secre- 
tion is  shown  in  different  ways.  Despite  careful  irrigation  scales  and 
flakes  are  seen  floating  in  the  fluid,  or  grayish  white  shreds  resembling 
snowflakes  are  observed  clinging  to  the  bladder-wall  or  floating  free 
in  the  liquid  medium  (Fig.  61). 

Tuberculous  cystitis,  according  to  my  experience,  only  rarely  gives 
charasteristic  pictures.  In  such  cases  nodules  circumscribed  by  a  dark 
red  border  are  seen ;  they  are  most  plentiful  on  the  floor  of  the  bladder 
(Figs.  66  and  67).     Advanced  cases  show  distinct  ulcers. 

Tumors  of  the  bladder  show  remarkably  beautiful  pictures  in  which 
polypi,  pedunculated    and  sessile  papillomata,  cauliflower  and  fram- 


Fig.  81.  Fig.  82.  Fig.  S3. 

besioid  excrescences  are  clearly  seen  projecting  from  the  bladder- walls 
(Figs.  68,  69,  70,  71,  72,  73,  74). 

Vesical  calculi  offer  not  less  profitable  pictures.  They  are  seen  either 
in  their  entirety  unsurrounded  by  the  mucosa,  or  partly  concealed 
by  it  (Figs.  75,  76,  77).  One  can  form  an  opinion  as  to  their  size  and 
shape,  discern  whether  they  are  smooth  or  rough,  and  also  recognize 
their  color;  from  these  attributes  conclusions  concerning  the  nature  of 
the  stone  can  be  drawn. 

Foreign  bodies,  such  as  catheters  and  hairpins  (Figs.  78  and  79)  are 
easily  seen  and  their  size  and  position  recognized. 

Vesicles  are  seen  most  frequently  at  the  sphincter  (Fig.  57).  White 
placques,  called  leucoplakia  vesicae,  are  shown  in  Fig.  80.     Groups 


44  PHYSICAL    METHODS    OF    EXAMINATION. 

of  red  pellucid  vesicles  resembling  clusters  of  grapes,  the  so-called 
oedema  bullosum,  are  shown  in  Fig.  81. 

A  catheter  lying  in  the  ureter  with  the  shadow  above  is  depicted  in 
Fig.  82,  while  in  Fig.  83  a  proliferation  of  tissue  often  found  at  the 
neck  of  the  bladder,  known  as  cystitis  colli  proliferate  cedematosa,  is 
displayed ;  it  may  be  mistaken  for  a  tumor. 

If  after  this  brief  sketch  we  were  to  review  the  practical  value  of 
cystoscopy  in  the  diagnosis  of  diseases  of  the  bladder,  we  should  say 
that  it  surpasses  all  methods  heretofore  employed  in  the  certainty  with 
which  it  enables  us  to  make  a  diagnosis  and  in  the  abundance  of  its 
results,  furnishing  us  as  it  does  with  a  means  of  recognizing  all 
pathologic  conditions  that  occur. 

Formerly  those  cases  of  hypertrophy  of  the  prostate  in  which  only  the 
vesical  portion  of  the  gland  was  involved  could  be  diagnosticated  only 
within  probability,  whereas  now,  the  cystoscope,  by  bringing  the  pro- 
tuberances directly  before  the  examining  eye,  makes  their  recognition 
absolutely  certain. 

For  the  diagnosis  of  cystitis  the  cystoscope  is  generally  not  required, 
although  by  its  use  tubercles  can  be  demonstrated  in  the  early  stages  of 
their  development,  before  the  specific  bacilli  are  found  in  the  urine. 
Therefore  the  methods  may  prove  of  great  value  in  certain  cases. 

Without  the  cystoscope  the  existence  of  ulcerations  of  the  bladder 
can  only  be  conjectured;  cystoscopy,  however,  makes  their  recognition 
certain. 

The  greatest  triumph  of  cystoscopy,  though,  is  in  vesical  tumors. 
While  it  is  true  that  in  most  cases  the  presence  of  tumors  can  be  inferred 
from  the  course  of  the  disease,  yet  the  symptoms  may  deceive  us  and 
sounding  and  palpation  may  fail  us,  whereas  cystoscopy  affords  assur- 
ance of  their  presence. 

A  matter  of  even  greater  importance  is  their  early  recognition  which 
cystoscopy  renders  possible.  Cases  in  which  the  course  of  the  malady 
furnishes  scarcely  an  inkling  as  to  the  nature  of  the  disease  are  made 
clear  by  inspection  of  the  bladder.  Thus  the  advantage  of  early  opera- 
tion is  conferred.  That  the  chances  of  cure  are  greater  the  earlier  the 
tumor  is  removed  requires  no  explanation.  In  many  cases  cystoscopy 
will  teach  us  the  kind  of  tumor  with  which  we  have  to  do,  and  finally  it 
will  apprise  us  of  the  location  of  the  growth. 

For  determining  the  site  of  the  growths  the  irrigation  cystoscope  is  of 
great  value.     If  the  bladder  be  examined  while  it  is  being  irrigated,  the 


CYSTOSCOPY.  45 

parts  composing  the  field  of  vision  will  be  replaced  by  others  previously 
concealed.  Therefore  this  method  is  especially  applicable  for  studying 
the  condition  of  the  pedicle  with  reference  to  subsequent  operation. 

As  far  as  vesical  calculi  are  concerned  the  sound  suffices  for  the 
majority  of  cases.  It  is  well-known,  however,  that  there  are  stones 
which  cannot  be  felt  despite  the  most  careful  examinations.  The  same 
thing  may  also  happen  in  cystoscopy,  a  stone  being  overlooked  though 
the  bladder  be  well  illuminated.  Such  failures  occur  especially  in  those 
difficult  cases  in  which  the  calculus  lies  embedded  in  a  saculation  and 
is  partly  covered  by  the  bladder-wall.  At  all  events  two  methods  will 
enable  us  better  to  avoid  making  an  erroneous  diagnosis  than  will  one. 

Cystoscopy  is  incontestably  better  than  any  other  method  of  examina- 
tion for  determining  the  presence  of  a  foreign  body  in  the  bladder.  It 
also  supplies  information  concerning  the  location,  form  and  size  of  the 
foreign  body,  and  makes  its  removal  per  vias  nalurales  possible  in  cases 
which  otherwise  would  have  to  be  subjected  to  a  cutting  operation. 

Finally  there  remains  to  be  mentioned  diseases  of  the  kidneys,  the 
diagnosis  of  which  made  an  unanticipated  advance  as  a  result  of  cys- 
toscopy. We  need  not  explain  how  difficult  it  was  in  many  cases  to 
determine  whether  bladder  or  kidney  was  the  seat  of  the  malady.  All 
the  aids  which  we  formerly  possessed  would  at  times  fail  us.  The 
course  of  the  disease,  palpation,  estimation  of  the  quantity  of  pus, 
polyuria  and  oliguria,  the  character  of  the  haemorrhages,  and 
microscopic  examination  were  in  many  cases  assuring,  but  in  others 
they  did  not  enable  us  to  reach  a  positive  diagnosis.  Here,  again, 
the  cystoscope  instituted  a  welcome  advance. 

By  examining  the  bladder  we  can  learn  whether  the  source  of  haem- 
orrhage be  here,  by  bringing  the  ureters  into  the  field  of  vision  we  can 
ascertain  whether  there  are  two  kidneys  and  watch  the  urine  coming  from 
each,  noting  whether  one  is  bleeding  and  whether  pus  is  issuing  from  one 
or  both  ureters. 

In  exceptionally  well-marked  cases  no  difficulties  are  offered,  but 
when  the  amount  of  pus  is  small  in  proportion  to  the  quantity  of  urine 
poured  out,  then  the  ingress  of  the  slightly  turbid  fluid  into  the  liquid 
medium  contained  within  the  bladder  is  perceived  only  with  difficulty, 
or  not  at  all;  when  the  pathologic  urine  is  clear  and  free  from  blood,  or 
contains  blood  only  in  microscopic  quantity,  it  will  be  quite  impossible 
to  make  a  diagnosis  by  observing  the  ureters. 

Cystoscopy  has  helped  us  over  these  difficulties  by  enabling  us  to 


46  PHYSICAL    METHODS    OF    EXAMINATION. 

catheterize  the  ureters  without  discomfort  or  injury  to  the  patient.  This 
can  be  easily  done  in  all  cases  in  which  the  ureters  are  visible ;  when  they 
lie  embedded  between  folds  of  mucous  membrane,  or  are  covered  over 
by  trabecular,  or  have  their  orifices  distorted  beyond  recognition,  then, 
naturally,  ureteral  catheterization  has  limitations.  Such  conditions, 
however,  are  exceptional.  In  most  cases  it  can  be  determined  with  cer- 
tainty even  in  the  earliest  stages  of  a  disease  not  only  whether  the  kidneys 
are  affected,  but,  moreover,  which  kidney  is  the  seat  of  the  affection. 
Furthermore,  an  idea  can  be  gained  as  to  how  far  the  other,  relatively 
healthy  kidney,  is  functionally  active,  and  thus  conclusions  drawn  as  to 
whether  operation  promises  results.  We  shall  discuss  these  conditions 
in  full  in  another  part  of  our  work. 

In  conclusion  we  will  say  a  few  words  in  regard  to  the  therapeutic 
value  of  cystoscopy.  There  can  be  no  correct  therapy  without  correct 
diagnosis.  As  cystoscopy  is  the  only  certain  method  of  diagnosis  in  a 
multitude  of  cases,  it  is  manifest  that  its  therapeutic  value,  though  in- 
direct, is  really  greater  than  its  diagnostic  value. 

But  cystoscopy  also  plays  a  direct  role  in  treatment  in  that  it  enables 
us  to  seize  favorably  located  tumors  with  the  snare  and  cut  them  off,  and 
to  cure  pyelitis  by  flushing  the  pelvis  of  the  kidney.  We  shall  refer  to 
these  things  again. 

ASEPSIS    OF    CATHETERIZATION    AND    CYSTOSCOPY. 

The  requisites  of  aseptic  catheterization  and  cystoscopy  are  three  in 
number;  namely,  i.  to  render  the  instruments  aseptic;  2.  to  keep  them 
aseptic;  3.  to  introduce  them  into  the  bladder  still  aseptic. 

The  disinfection  of  catheters  and  the  cystoscope  must  be  considered 
separately. 

All  kinds  of  catheters — Nelaton's,  the  silk- web,  the  English  and  metal 
instruments — can  be  sterilized  with  boiling  water,  the  only  difference 
being  that  all  soft  instruments  have  to  be  boiled  for  five  minutes  in  a 
super-saturated  solution  of  ammonium  sulphate,  while  for  metal  instru- 
ments plain  water  may  be  used.  The  ammonium  solution  is  not  to  be 
used  for  metal  instruments  because  it  makes  them  unsightly  in  appear- 
ance, and  it  is  required  for  soft  instruments  only  when  they  must  be 
sterilized  quickly.  When  there  is  sufficient  time  for  their  preparation 
they  may  be  done  up  separately  in  lint  or  linen  clothes  and  kept  for  two 
hours  in  a  steam  sterilizer.  This  latter  method  is  the  best  one  for  the 
long,  slender  ureteral  catheters. 


cystoscopy.  47 

The  striking  point  about  this  method  of  sterilization  is  that  the 
catheters  do  not  touch  one  another,  and  that  the  parts  of  an  individual 
catheter  do  not  come  in  contact;  otherwise  the  varnished  silk- webbed 
catheters,  in  which  class  ureteral  catheters  also  belong,  would  become 
sticky.  Each  catheter  must  therefore  be  wound  up  separately.  If  this 
be  done  they  will  remain  in  good  condition,  neither  looks  nor  consis- 
tency being  affected,  whereas  repeated  boiling  in  ammonium  solution 
makes  them  soft  and  unsightly.  Thus  it  is  seen  that  while  metal  in- 
struments always  should  be  boiled,  the  pliable  ones  should  be  so  treated 
only  when  it  is  necessary  to  sterilize  them  in  a  patient's  house,  or  when 
already  sterilized  ones  cannot  easily  be  obtained.  In  hospital  and  dis- 
pensary practice  it  will  be  found  most  convenient  to  sterilize  them  in  a 
steam  sterilizer,  tying  up  a  number  of  similar  instruments,  each  in- 
dividual one  being  wound  around  with  cotton  or  lint  as  previously  de- 
scribed, and  put  into  a  cloth,  having  one  for  Nelaton  catheters,  one  for 
silk -web,  one  for  Mercier's,  and  so  on. 

Both  methods,  either  boiling  for  five  minutes  or  sterilizing  by  steam 
for  two  hours,  renders  the  instruments  thoroughly  aseptic.  As  regards 
vesical  catheters  it  has  long  been  known  that  these  methods  suffice,  so  it 
is  not  necessary  to  adduce  experimental  proof  of  the  fact.  Whether  the 
slender  ureteral  catheters  could  be  made  aseptic  by  subjecting  them  to 
steam  sterilization  required  demonstration,  and  so  for  the  purpose  of 
deciding  the  question  I  instituted  the  following  experiment.  The  cath- 
eters were  thoroughly  soaked  inside  and  outside  in  streptococcic 
bouillon  and  after  being  dryed  were  placed  in  the  steam  sterilizer  for 
two  hours,  and  then  cultures  taken  from  them  in  two  tubes  of  bouillon 
and  two  Petri  dishes  of  fluid  agar.  These  four  culture  media  remained 
sterile  after  three  inoculations. 

In  reference  to  keeping  the  catheters  sterile,  the  method  of  sterili- 
zation by  steam  is  to  be  preferred,  as  the  instruments  remain  perfectly 
aseptic  as  long  as  they  are  not  taken  out  of  the  cloth  in  which  they  are 
done  up,  and  it  is  not  necessary  to  take  them  out  until  just  before  they 
are  to  be  used.  Boiled  instruments  must  be  kept  in  sterilized  cases,  as  it 
does  not  do  to  leave  them  in  the  ammonium  solution  because  they  become 
soft  and  also  lose  their  smoothness.  That  their  transference  to  sterile 
cases  complicates  the  proceeding  is  self-evident. 

If  the  patient  has  to  catheterize  himself,  I  find  the  best  method  for  him 
to  employ  is  to  place  the  instrument,  after  washing  it  carefully  in  run- 
ning water,  in  a  i :  iooo  solution  of  corrosive  sublimate,  laying  it  horizon- 


48  PHYSICAL    METHODS    OF    EXAMINATION. 

tally,  so  that  the  fluid  can  gain  access  to  the  inside  of  the  catheter  as  well 
as  coming  in  contact  with  its  exterior.  Enamel  catheter-cases  are  the 
best.  The  instrument  is  kept  in  one  for  twenty-four  hours  and  then 
taken  out  and  laid  on  a  sterile  towel  or  a  clean  handkerchief.  It  can  be 
used  at  once  or  be  rolled  up  in  the  cloth  until  it  is  used. 

That  the  sublimate  solution  remaining  on  the  catheter  produces  irrita- 
tion of  the  urethra  is  a  tradition  which  1  have  not  been  able  to  confirm, 
and,  moreover,  is'  one  which  has  no  probability,  because  the  catheter  is 
smeared  with  a  lubricant,  so  that  the  sublimate  does  not  come  in  contact 
with  the  urethra.  However,  if  it  be  desired,  the  instrument  may  be 
rinsed  with  sterile  water. 

The  cystoscope  requires  different  treatment  than  sounds  and  catheters, 
for  it  bears  neither  boiling  nor  heat  of  the  sterilizer  even  though  its 
ocular  be  protected.  The  reason  why  it  cannot  be  heated  to  ioo°  C.  or 
more  is  because  the  prism  is  cemented  into  a  solid  metal  setting.  This 
accouplement  between  metal  and  glass  withstands  the  heat  very  badly 
because  the  expansion  of  the  two  materials  is  entirely  different.  Further- 
more, as  the  cement  used  to  unite  the  two  has  a  special  expansiveness,  it 
is  impossible  to  prevent  the  prism  from  becoming  loosened  by  repeated 
boilings  and  thereby  permit  water  to  gain  access  to  the  space  produced 
between  the  prism  and  its  setting.  The  manner  in  which  further  dam- 
age is  done  depends  entirely  upon  circumstances.  If  it  should  happen 
now  and  then  that  a  cystoscope  be  heated  repeatedly  to  ico°  C.  without 
injuring  it  and  allowing  water  to  get  into  it,  the  circumstance  must  be 
considered  as  altogether  fortuitous. 

Boiling  is  also  impossible  on  account  of  the  sensitiveness  of  the  reflect- 
ing surface  of  the  prism,  its  silvering  being  very  susceptible  to  the  in- 
fluence of  gross  oscillations  of  temperature  such  as  are  produced  by  boil- 
ing. It  has  been  known  for  years  that  laryngeal  mirrors,  even  though 
their  setting  is  the  best,  bear  boiling  only  a  few  times.  The  reason  for 
the  delicacy  of  these  mirrored  surfaces  lies  in  the  fact  that  they  are  not 
composed  of  a  single  stratum,  but  of  two  layers  having  a  very  minute 
space  between  which  steam  or  gas  can  force  an  entrance  and 
cause  oxidation  of  the  silvering,  as  the  result  of  which  the  clearness  of  the 
reflected  image  becomes  impaired. 

Protection  of  the  prism  from  fluid  by  setting  it  with  waterproof  cement 
is  practically  worthless,  because  there  is  an  air-space  within  the  cysto- 
scope itself  which  cannot  be  occluded.  Much  more  dangerous  than  the 
moisture   surrounding  the  instrument  is  the  steam  generated  within  it 


cystoscopy.  49 

and  thrown  against  the  prism.  A  further  disadvantage  of  heating  the 
cystoscope  lies  in  the  fact  that  the  moisture  remains  in  the  form  of  steam 
until  the  instrument  cools  and  is  then  gradually  condensed  upon  the  glass 
and  metal  walls.  As  the  humidity  absorbs  everything  soluble,  it  is  evi- 
dent that  when  it  is  condensed  deposits  will  be  made  upon  the  surface 
of  the  prism  and  lenses  which  will  be  both  troublesome  and  injurious. 

For  these  reasons  I  have  also  abandoned  immersing  the  cystoscope  for 
twenty-four  hours  in  5  per  cent  carbolic  acid  solution,  and  have  adopted 
a  method  of  sterilization  which  has  proved  to  be  most  satisfactory.  This 
method,  which  is  similar  to  the  one  used  by  Karl  Gerson  for  cutting 
instruments,  is  applied  as  follows :  the  cystoscope  and  the  undetachable 
parts  of  the  urethroscope  are  rubbed  with  three  cloths  and  compresses 
of  cotton  dipped  in  spiritus  saponatus  [a  preparation  official  in  the  Ger- 
man pharmacopoeia;  an  alcohol  or  ethereal  solution  of  green  soap  may  be 
used  instead],  each  being  used  for  one  minute  and  special  attention 
being  given  to  the  borders  and  angles.  After  this  has  been  done  the  in- 
strument is  wound  up  in  a  sterile  towel  likewise  wet  with  the  solution  of 
soap  and  allowed  to  remain  until  it  is  used.  The  removable  metal  parts 
of  my  ureteral  cystoscope  are  boiled  for  five  minutes.  I  have  proved 
experimentally  that  a  cystoscope  thus  prepared  is  perfectly  sterile  and 
that  it  remains  so  until  used. 

Unfortunately  this  method  cannot  be  used  for  sterilizing  catheters  be- 
cause it  does  not  fulfill  the  prerequisite  of  rendering  the  inside  of  the  in- 
struments aseptic;  according  to  Gerson,  however,  it  may  be  employed 
for  bougies. 

The  first  two  requirements  of  asepsis,  that  is,  to  sterilize  the  instru- 
ments and  keep  them  sterile,  can  be  carried  into  effect  by  employing  the 
methods  above  described,  and  we  have  now  to  consider  the  feasibility  of 
fulfilling  the  third  requirement,  which  is  to  preserve  their  asepticity  from 
the  time  they  are  taken  from  their  sterile  container  until  they  have  reached 
the  bladder.  We  say  feasibility  purposely,  for  the  requ'rement  can- 
not be  entirely  accomplished  because  the  instruments  have  to  pass 
through  the  urethra,  which,  as  is  well-known,  contains  microorganisms 
even  when  in  a  healthy  condition.  To  attempt  to  get  rid  of  these  organ- 
isms is  a  vain  endeavor.  Moreover,  it  has  not  been  determined  whether 
these  parasitic  inhabitants  of  the  urethra  infect  the  bladder  even  though 
they  do  gain  access  to  it.  These  questions  become  abeyant  to  the  more 
important  one  of  securing  a  lubricant  for  the  instruments  which  shall 
neither  carry  infection  nor  facilitate  its  development. 
4 


50  PHYSICAL    METHODS    OF    EXAMINATION. 

Oil,  which  is  most  frequently  used  at  present,  is  not  at  all  suitable. 
It  can  be  sterilized  only  by  boiling,  and  to  boil  oil  is  both  difficult  and 
dangerous.  It  cannot  be  used  on  the  cystoscope  because  it  greases  the 
prism  and  thereby  injures  the  picture.  The  same  applies  to  vaseline 
and  lanoline.  In  addition  to  these  disadvantages  there  is  another  more 
important  one  to  which  too  little  attention  has  been  paid.  Oil  and  fats 
form  an  adherent  coating  on  catheters  which  is  not  dissolved  by  steriliz- 
ing processes  and  thus  acts  as  a  protective  covering  for  germs.  This  is 
especially  true  of  the  sublimate  disinfection  recommended  for  use  by 
patients  themselves,  as  the  mercurial  solution  is  prevented  from  coming 
in  contact  with  the  catheters  by  the  protective  layer  of  fat.  Therefore  it 
may  be  said  that  the  use  of  fatty  lubricants  directly  favors  infection. 

For  this  reason  I  long  since  abandoned  oil  and  vaseline  for  glycerine, 
which  is  superior  to  them,  but  which  is  not  fit  for  use,  its  disadvantages 
being  greater  than  its  advantages.  It  must  be  boiled  in  order  to  be 
aseptic.  Disagreeable  vapors  are  given  off  and,  moreover,  boiling  is  very 
difficult.  Besides  it  is  not  slippery  enough.  It  answers  fairly  well  for 
easy  catheterizations,  but  for  difficult  ones  where  it  is  necessary  to  have 
the  instrument  thoroughly  lubricated  it  fails. 

In  view  of  the  above  mentioned  reasons  I  have  adopted  a  lubricant 
similar  to  one  previously  recommended  by  Guyon  and  Kraus.  It  is 
composed  of  a  definite  quantity  of  glycerine,  water,  and  tragacanth.  It 
seemed  essential  to  incorporate  in  place  of  the  carbolic  acid  recom- 
mended by  Kraus  an  antiseptic  which  would  preserve  the  lubricant  for 
a  long  time,  and  which,  moreover,  would  not  irritate  the  urethra.  After 
many  trials  such  a  one  was  found  in  the  oxycyanate  of  mercury,  which 
is  used  in  the  strength  of  i :  500.  The  lubricant,  which  is  sold  in  Germany 
under  the  name  of  katheterpurin,  has  the  following  composition: 

Hydrarg.  oxycyanat 0.246  (gr.  iii  ss) 

Glycerini   20.0  (f qvss) 

Tragacanth 3.0  (gr.  xlvt) 

Aquae  dest.  steritisat 100. o  (f  o  iii) 

The  mixture  is  put  up  in  tin  tubes.* 

For  practical  purposes  the  result  of  my  investigations  proving  that 
this  lubricant  remains  sterile  eight  days  after  being  exposed  to  the  air 
is  a  most  important  one,  showing  that  catheters  and  sounds  smeared 

*[Any  pharmacist  can  prepare  this  mixture.] 


CYSTOSCOPY.  51 

with  it  suffer  no  damage  as  to  their  asepticity.  Moreover,  it  has  the 
power  of  destroying  or  inhibiting  the  virulence  of  any  microorganisms 
which  may  be  met  with,  provided,  of  course,  that  they  be  brought  into 
close  contact  with  it.  To  what  degree  this  intimate  contact  actually 
occurs  is  altogether  conjectural. 

As  this  compound  is  found  experimentally  to  fulfill  the  requirements 
theoretically  demanded  of  a  lubricant,  so  likewise  is  it  found  in  practice 
to  possess  all  the  necessary  requisites.  No  cases  of  infection  traceable 
to  its  use  have  occurred;  it  does  not  irritate  the  urethra;  it  makes  the 
instruments  exceptionally  smooth  and  slippery;  it  is  soluble  in  water,  so 
that  it  does  not  prevent  instruments  from  being  sterilized  or  washed  by 
forming  an  adherent  coating  full  of  bacteria;  it  does  not  act  injuriously 
upon  the  cystoscope,  inasmuch  as  it  quickly  dissolves  in  the  fluid 
present  in  the  bladder,  and  does  not  diminish  the  clearness  of  the 
picture;  and,  finally,  as  it  is  put  up  in  tin  tubes,  it  can  be  used  without 
any  preparation. 

With  this  it  is  seen  that  the  third  necessity  for  aseptic  catheterization 
and  cystoscopy  is  secured.  It  has  already  been  stated  that  the  urethra 
cannot  be  rendered  sterile.  Our  chief  aim,  therefore,  must  be  to  render 
harmless  those  microorganisms  which  despite  our  precautions  get  into 
the  bladder. 

For  catheterization  this  end  may  be  secured  by  giving  a  prophylactic 
irrigation  of  the  bladder  with  100-200  cc.  [3  to  6  ounces]  of  a  1.1000 
or  a  1.2000  solution  of  silver  nitrate;  for  cystoscopy  I  use  a  fluid  which, 
if  not  strongly  antiseptic,  nevertheless  possesses  the  power  of  materially 
inhibiting  the  development  of  bacteria.  Corrosive  sublimate  and  carbolic 
acid  are  not  suitable  because  they  irritate  the  bladder,  are  painful,  and 
produce  contractions  of  the  viscus.  The  fluid  employed  must  be 
limpid,  transparent,  and  non-irritating.  In  place  of  the  formerly 
employed  boric  acid  solution  I  now  use  a  1.5000  solution  of  oxycya- 
nate  of  mercury,  which  is  perfectly  clear,  non-irritating,  and  painless, 
and  which  considerably  diminishes  propagation  of  microbes  if  it  does 
not  entirely  inhibit  their  growth.  1  am  now  using  this  substance  for 
irrigating  the  bladder  in  all  cases  in  which  I  formerly  employed  boric 
acid. 

4.    DIGITAL  EXAMINATION  OF  THE  BLADDER. 

The  examination  of  the  male  bladder  with  the  finger  has  been  entirely 
abandoned.     About  twenty  years  ago  Thompson  recommended  this 


52 


PHYSICAL    METHODS    OF    EXAMINATION. 


procedure  for  the  purpose,  of  diagnosticating  tumors.  The  examina- 
tion was  made  through  a  median  incision.  This  procedure  has  been 
replaced  by  cystoscopy. 

In  the  female  there  may  be  cases  in  which  it  is  advisable  to  palpate 
the  bladder  with  the  finger.  G.  Simon  has  demonstrated  that  the  female 
urethra  can  be  sufficiently  dilated  with  specula  to  admit  the  introduction 
of  the  finger  into  the  bladder.     His  instruments  are  graduated,  conical 


Fig,  84. — Simon's  speculum. 

hard  rubber  specula  provided  with  obturators  (Fig.  84).  General 
anaesthesia  is  not  necessary,  cocainization  of  the  urethra  being  quite 
sufficient.  If  tears  are  produced,  they  should  be  sutured  immediately 
after  completion  of  the  examination,  in  order  to  prevent  paralysis  of  the 
sphincter. 

5.  EXAMINATION  WITH  THE  RONTGEN  RAYS. 

Rontgen's  epoch-making  discovery  has  been  made  use  of  in  the  diag- 
nosis of  diseases  of  the  bladder  and  kidneys.  Up  to  the  present  time, 
however,  the  only  objects  we  have  succeeded  in  portraying  with  enough 
accuracy  to  make  their  recognition  positive  are  stones  and  foreign 


EXAMINATION    WITH    THE    RONTGEN    RAY. 


53 


bodies.     In  all  other  affections  the  method  fails.     Moreover,  it  is  not 
always  successful  in  the  case  of  calculi  and  foreign  bodies. 


Fig.  85. — Hairpin  in  the  bladder.     (Dr.  Levy-Dorn). 


Fig.  86. — Phosphatic  renal  calculus  (Dr.  Levy-Dorn). 

In  regard  to  foreign  bodies  it  may  be  said  that  metal  objects  such  as 


54  PHYSICAL    METHODS    OF   EXAMINATION. 

needles  and  hairpins  take  the  best  pictures.  Figure  85  shows  a  very 
good  picture  of  a  hairpin  in  the  bladder.  The  Rontgen  rays  are  not 
absorbed  by  catheters,  drainage  tubes,  etc.,  and  therefore  these  objects 
are  not  visible  on  the  photographic  plate.  Figure  86  shows  a  picture  of  a 
renal  calculus  (phosphatic).  Those  composed  of  oxalates  show  the  best. 

In  addition  to  the  difficulties  presented  by  the  objects  themselves 
there  are  individual  peculiarities  which  affect  the  value  of  actinography 
as  a  diagnostic  expedient.  Thus,  for  example,  X-ray  pictures  of  fat 
persons  are  almost  always  failures,  while  in  those  who  are  thin  they  are 
more  likely  to  be  valuable,  as  in  this  class  the  rays  penetrate  better  than 
in  the  corpulent. 

Therefore,  this  method,  which  is  to  be  hoped  will  be  improved  and 
perfected,  may  be  tried  as  a  supplementary  and  very  refined  means  of 
diagnosis,  but  it  must  be  remembered  that  a  negative  result  is  not  con- 
clusive evidence  that  a  stone  or  foreign  body  is  not  present. 


PHYSICAL    PROPERTIES    OF    THE    URINE.  55 


III.     PHYSICAL,   CHEMICAL   AND    MICROSCOPIC  EXAM- 
INATION  OF  THE   SECRETIONS. 

Under  this  title  we  shall  not  describe  the  various  secretions  which 
are  discharged  through  the  urethra,  such  as  the  prostatic  fluid  and 
semen,  because  they  are  discussed  under  the  headings  of  specific 
diseases.  We  shall  devote  our  attention  here  to  the  urine.  An  ade- 
quate knowledge  of  its  normal  and  pathologic  properties  forms  the 
foundation  of  every  diagonsis. 

I.    PHYSICAL  PROPERTIES  OF  THE  URINE. 

The  quantity  of  urine  voided  by  a  healthy  adult  in  twenty-four  hours 
usually  averages  1500  cc.  (50  ounces).  Abnormal  conditions  such  as 
profuse  sweating  or  copious  ingestion  of  fluid  may  cause  great  varia- 
tions, either  diminishing  or  increasing  the  average  quantity.  A  lessened 
or  augmented  quantity  of  urine  is  not  pathologic,  however,  unless  it 
persists  for  some  time  and  occurs  irrespective  of  the  above  mentioned 
causes. 

The  color  of  the  urine  is  golden  yellow,  although  such  variations 
occur  in  health  that  an  almost  colorless  urine  having  only  a  slight 
tinge  of  yellow,  as  well  as  one  brownish  red  in  hue  may  be  considered 
normal.     Concentration  plays  an  important  role  in  coloring  the  urine. 

The  specific  gravity  of  the  urine  depends  upon  the  weight  of  the  ele- 
ments which  it  holds  in  solution.  Normally  it  averages  from  10.15 
to  10.20,  although  here  again  fluctuations  occur:  the  greater  the 
amount  of  urine  passed  in  a  given  time  the  lighter  is  its  specific  gravity, 
and  vice  versa.  The  specific  gravity  is  taken  with  the  ureometer, 
the  figure  at  the  meniscus  being  read  off. 

The  average  analysis  of  the  total  quantity  of  urine  for  twenty-four 
hours — 1500  cc. — is  as  follows: 

Water  1440  grammes,  solids  60  grammes,  of  which  35  grm.  are 
organic  and  25  inorganic. 

Urea 35.  g     ) 

TT  .       . j  ,-  Organic. 

Uric  acid 0.75  g  ) 

Sodium  chloride 16.5      j 

Salts  of  phosphoric  acid  (Ca.  Mg.  N.  K.)  6.0       -  Inorganic. 
Salts  of  sulphuric  acid 3.0      1 


56  PHYSICAL,    CHEMICAL,    AND    MICROSCOPIC    EXAMINATION. 

[The  urine  also  contains  substances  closely  related  to  urea — xanthin, 
creatin,  creatinin;  the  ethereal  sulphates  of  phenol,  cresol,  incloxyl  and 
skatoxyl;  hippuric  acid,  aromatic  oxyacids,  and  pigments]. 

The  quantity  of  the  urine  and  its  specific  gravity  stand  in  inverse 
proportion  to  one  another.  If  the  quantity  be  increased  the  gravity, 
under  normal  conditions,  will  fall,  and  vice  versa.  A  disproportion 
between  the  two  points  to  some  pathologic  condition. 

The  amount  of  solids  in  the  urine  can  be  estimated  approximately  by 
multiplying  the  last  two  figures  of  the  specific  gravity  by  Haeser's  co- 
efficient, which  is  2.33.  This  gives  the  number  of  grammes  of  solids  in 
1000  cc.  of  urine. 

Example  for  normal  urine:  quantity  for  twenty-four  hours  150  cc. 
specific  gravity  10.17. 

2.33X17^39-61  g.  for  1000  cc.  of  urine. 
19.80  g.  for    500  cc.  of  urine. 

59.41  approximately  60.0  g.  for  1500  cc. 
Example  for  diabetes:   quantity  for  twenty- four  hours  6000  cc. 
specific  gravity  10.35. 

2-33X35=l8l-55  g-  for  IOO°  cc- 
6 

489.30  g.  for  6000  cc. 

In  diabetes  the  gravity  is  enormously  increased  as  well  as  the  quantity 
of  urine  voided. 

Example  for  contracted  kidney:  quantity  4000  cc.  specific 
gravity  10.04. 

2.33X04^9.32  for  1000  cc. 

4 

37.28  for  6000  cc. 

In  contracted  kidney  (chronic  interstitial  nephritis)  the  gravity 

is  much  diminished  despite  the  existence  of  polyuria. 

Normal  urine  is  clear  and  transparent  and  has  an  aromatic  odor  some- 
what resembling  that  of  bouillion.  It  is  acid  in  reaction,  the  acidity 
being  due  to  acid  mono-phosphate  of  sodium.  The  reaction,  however, 
depends  upon  the  kind  of  food  ingested,  a  meat  diet  making  it  acid  and 
a  diet  rich  in  vegetables,  as  well  as  the  drinking  of  alkaline  mineral 
waters,  making  it  alkaline.     As  the  vegetable  acids  (citric,  malic,  acetic, 


CHEMICAL    EXAMINATION    OF    THE    URINE.  57 

tartaric)  are  converted  into  alkaline  carbonates  in  the  blood,  their  use 
causes  a  diminution  in  the  acidity  of  the  urine,  rendering  it  neutral  or 
even  alkaline  (dietetic  phosphaturia,  carbonaturia). 

The  reaction  of  the  urine  is  tested  with  litmus  paper,  acid  urine  turn- 
ing blue  litmus  red  and  alkaline  turning  red  litmus  blue.  It  may  also 
be  amphoteric,  that  is,  it  may  turn  red  litmus  blue  and  blue  litmus  red. 
This  property  is  present  when  in  addition  to  mono-phosphate  of  sodium 
the  urine  contains  the  alkaline  sodium  diphosphate.  It  is  not  significant 
of  any  morbid  condition. 

If  the  urine  is  alkaline  and  its  alkalinity  cannot  be  referred  to  diet, 
then  the  condition  is  due  either  to  fixed  alkalies  or  to  ammoniacal 
decomposition.  In  the  latter  case,  if  a  piece  of  red  litmus  paper 
be  hung  in  a  bottle  containing  the  urine,  but  in  such  a  manner  that 
the  urine  does  not  touch  it,  it  will  be  turned  blue  by  the  escaping 
alkaline  gases,  while  in  the  first  case  it  will  retain  its  red  color. 

2.    CHEMICAL  EXAMINATION  OF  THE  URINE. 

It  is  my  practice  to  collect  the  urine  to  be  examined  in  two  portions. 
The  first  consists  of  the  urine  from  the  bladder  mixed  with  the  secretions 
taken  up  by  it  in  its  passage  through  the  urethra,  while  the  second  con- 
sists solely  of  urine  from  the  bladder.  This  is  of  great  importance.  If, 
for  instance,  we  wish  to  test  for  albumen  and  do  not  observe  this  pre- 
caution, any  purulent  secretion  present  in  the  urethra  would  cause  a 
positive  reaction ;  for  whenever  there  is  pus  in  the  urine  there  is  also 
albumen,  it  being  derived  from  the  protoplasm  of  the  pus  corpuscles. 
In  a  case  of  this  kind  we  would  have  to  do  with  what  is  known  as 
albuminuria  spuria,  which  is  of  an  entirely  different  significance  than 
albuminuria  vera,  with  which  we  most  frequently  have  to  do. 

A.    TESTS  FOR  ALBUMEN. 

By  albuminous  urine  in  the  general  sense  of  the  term  we  mean  a 
urine  containing  serum-albumin  and  serum-globulin,  the  excretion  of 
these  substances  constituting  the  clinical  conception  of  albuminuria. 

A  urine  to  be  tested  for  albumen  must  be  clear.  If  it  is  turbid  it 
must  be  filtered  repeatedly  until  the  filtrate  is  clear.  If  it  does  not 
become  clear  after  simple  filtration,  it  maybe  shaken  with  calcined  mag- 
nesia, lime-water,  barium  carbonate,  or  charcoal,  and  the  resulting  mix- 
ture  filtered. 

For  clinical  purposes  the  following  qualitative  tests  fully  suffice: 


58  CHEMICAL,    PHYSICAL,    AND    MICROSCOPIC    EXAMINATION. 

(a)    THE    HEAT    TESTS. 

If  clear  acid  urine  containing  albumen  be  boiled  it  becomes  turbid. 
As  a  turbidity  also  arises  from  the  presence  of  earthy  phosphates  a  few 
drops  of  nitric  or  acetic  acid  are  added  to  the  boiled  urine;  these  acids 
clear  up  the  turbidity  produced  by  the  earthy  phosphates,  but  do  not 
affect  that  caused  by  albumen. 

Albumen  may  be  present  and  yet  no  cloudiness  appear  on  boiling; 
this  occurs  in  alkaline  urine  in  which  the  albumen  combines  with  certain 
bases  which  are  present,  especially  potassium,  forming  albuminates 
which  are  not  soluble  by  heat.  If  in  such  cases  acetic  or  nitric  acid 
be  added  drop  by  drop  to  the  clear  boiled  urine  the  albumen  will  be 
precipitated. 

Owing  to  this  property  of  potassium  albuminate  it  was  formerly 
recommended  to  acidulate  the  urine  with  acetic  acid  before  boiling, 
but  such  a  procedure  is  not  to  be  advised,  because  if  an  excess  of  the 
acid  be  added  a  soluble  combination  of  acid  albumen  is  formed  which 
is  not  precipitated  by  heat.  If  it  be  desired  to  acidulate  the  urine 
before  boiling  it,  then  only  a  few  drops  of  nitric  acid  should  be  added. 

(b)      THE    NITRIC    ACID    TEST  (HELLER'S    TEST). 

The  urine  is  put  into  a  test  tube  and  a  few  cubic  centimeters  of 
concentrated  nitric  acid  allowed  to  run  down  the  side  while  the  tube 
is  inclined;  or  the  acid  may  be  put  into  a  reagent-glass  and  the  urine 
allowed  to  fall  upon  it  drop  by  drop  through  a  filter.  In  either  case 
the  two  fluids  must  not  intermingle.  If  albumen  is  present  a  white 
or  grey  ring  will  form  where  the  two  fluids  come  in  contact. 

This  ring  must  not  be  confused  with  the  brown  ring  which  is 
formed  in  every  urine,  whether  it  be  albuminous  or  non-albuminous, 
and  which  consists  of  urea  nitrate. 

Resinous  acids  due  to  the  ingestion  of  turpentine,  copaiba,  and 
sandal-oil  may  be  mistaken  for  albumen,  as  they  make  a  yellowish- 
white  ring  when  brought  in  contact  with  nitric  acid.  If  the  question 
of  their  presence  arise  apply  the  heat  test.  A  cloudiness  will  ensue, 
but  it  will  disappear  upon  adding  an  excess  of  alcohol  and  thoroughly 
shaking  the  tube. 

(c)      ACETIC    ACID    AND    POTASSIUM    FERROCYANIDE    TEST. 

The  urine  is  acidulated  with  acetic  acid  and  then  a  fewr  drops  of  a 
10  per  cent  solution  of  potassium  ferrocyanide  added.     If  albumen 


CHEMICAL    EXAMINATION    OF    THE    URINE.  59 

be  present  a  flocculent  precipitate,  or  perhaps  only  a  slight  turbidity, 
is  produced,  the  intensity  of  the  reaction  depending  upon  the  quantity 
of  albumen  present.  This  test  is  extraordinarily  sensitive  and  there- 
fore especially  appropriate  for  demonstrating  small  quantities  of 
albumen. 

(d)     SULPHO-SALICYLIC    ACID   TEST. 

This  is  a  still  more  delicate  test.  It  is  performed  by  adding  a  few 
drops  of  a  20  per  cent  solution  of  sulpho- salicylic  acid  to  the  suspected 
urine,  whereupon,  if  albumen  be  present  even  in  the  minutest  quantity, 
a  cloudiness  will  be  produced. 

QUANTITATIVE    ESTIMATION    OF    ALBUMEN. 

The  heat  test  yields  approximate  quantitative  results  which  are 
given  in  the  following  table: 

Solid  coagulation  of  the  entire  quantity  of  urine  represents  2-3  %  of  albumen 
«    ithe  ..         ..      ..  ..         j      %  .< 

i    "                 "         "  "             "  0.5  %  "         " 

"    {    "                "         "  "             "  0.25%  «' 

"    1-10                 "          "  "              "  0.1  %  " 

Coagulation  only  at  the  surface  of  the  fluid  °-°5%  " 

Slight  cloudiness  but  no  coagulum  "  0.01%   " 

A  more  accurate  but  still  only  approximative  test  is  that  made  with 
Esbach's  albuminometer  (Fig.  87).  To  estimate  the  quantity  of  albu- 
men fill  the  tube  to  the  line  marked  U  with  urine  which  has  been  slightly 
acidulated  with  acetic  acid  and  then  add  Esbach's  solution  of  picric 
acid  (acid  picric  10  grammes,  or  155  grains;  citric  acid  20  grammes,  or 
310  grains;  water  enough  to  make  1000  cubic  centimeters,  or  33^  fluid 
ounces)  up  to  the  line  marked  R. 

Mix  the  liquids  by  reversing  the  tube  a  few  times  and  allow  it  to  stand 
for  twenty-four  hours.  The  coagulum  of  albumen  which  forms  is  read 
off  on  the  scale,  the  number  with  which  it  is  level  denoting  the  number 
of  parts  of  albumen  per  liter.  [This  number  divided  by  10  gives  the 
percentage.] 

[For  rapid  and  accurate  quantitative  estimation  I  have  found 
Purdy's  centrifugal  method  very  satisfactory.  It  is  performed  as  fol- 
lows: into  a  graduated  centrifuge  tube  having  a  capacity  of  15  cc.  pour 
10  cc.  of  urine,  3  cc.  of  a  1  to  10  aqueous  solution  of  potassium  ferro- 
cyanide,  and  2  cc.  of  50  per  cent  acetic  acid.  Mix  thoroughly,  and  after 
allowing  the  tube  to  stand  for  ten  minutes,  place  it  in  Purdy's  electrical 


6o 


CHEMICAL,    PHYSICAL,    AND    MICROSCOPIC    EXAMINATION. 


centrifuge  (or  any  other  having  a  radius  of  6f  inches)  and  revolve  for 
three  minutes  at  the  rate  of  fifteen  hundred  (1500)  revolutions  per 
minute.  The  coagulum  of  albumen  is  then  read  off  on  the  graduated 
scale,  the  number  with  which  it  is  level  representing  the 
bulk  percentage.  The  late  Dr.  Chas.  W.  Purdy,  of 
Chicago,  who  originated  this  method,  carefully  com- 
pared the  results  obtained  by  it  with  those  obtained  by 
the  gravimetric  method  and  found  that  they  did  not 
vary  more  than  0.0 1  per  cent.] 

B.    ALBUMOSURIA  OR  PROPEPTONURIA. 

In  addition'  to  albumen  another  substance  called 
hemi-albumose,  or  propepton,  is  sometimes  present  in 
the  urine.  If  nitric  acid  be  added  to  it  coagulation 
occurs,  but  the  coagulum  dissolves  upon  heating. 
This  property  distinguishes  it  from  albumen.  The 
excretion  of  this  substance  constitutes  albumosuria  or 
propeptonuria. 

If  it  be  found  that  the  coagulum  produced  by  nitric 
acid  becomes  smaller  when  heated  and  assumes  its 
original  size  after  cooling,  propepton  is  to  be  suspected. 
To  determine  its  presence  add  to  the  urine  ^  its  volume 
of  concentrated  salt  solution  and  a  few  drops  of  acetic 
acid  and  boil.  Filter  the  mixture  while  hot,  and  if 
propepton  be  present  it  will  show  as  a  coagulum  in 
the  cooled  filtrate. 

C.    THE  BIURET  TEST. 

If  albuminous  urine  (that  containing  albumen  or 
hemi-albumose)  be  rendered  alkaline  with  potassium  or  sodium  hy- 
drate and  then  boiled,  and  a  few  drops  of  a  10  per  cent  solution  of 
copper  sulphate  added,  a  violet-red  color  will  be  produced. 

This  test  serves  also  for  the  detection  of  peptone,  the  presence  of 
which,  however,  will  be  questionable  for  the  reason  that  both  albumen 
and  hemi-albumose  give  the  reaction,  as  has  just  been  stated.  If  these 
substances  be  absent  the  test  may  be  used  for  the  detection  of  peptone. 

Considerable  obscurity  prevails  in  regard  to  albuminuria  due  to 
pus  and  blood.  If  urine  containing  either  be  filtered  repeatedly  until 
it  becomes  perfectly  clear,  it  will  nevertheless  contain  albumen,  because 


Fig.  87. — Esbach's 
albuminometer. 


CHEMICAL    EXAMINATION    OF    THE    URINE.  6 1 

some  of  the  protoplasm  of  the  pus  and  blood-corpuscles  has  been 
dissolved  by  the  urine  and  cannot  be  removed  by  nitration.  This 
quantity  of  albumen,  however,  is  never  very  large;  when  due  to  solution 
of  pus  it  does  not  exceed  i. 5-1000,  and  when  due  to  solution  of  blood 
it  does  not  go  higher  than  1-2000. 

D.    TESTS  FOR  SUGAR. 

Minute  quantities  of  glucose  (grape-sugar)  are  present  in  normal 
urine.  These  traces  are  not  demonstrable  by  the  practicable  tests 
which  we  are  about  to  describe  and  so  do  not  require  our  consideration. 

As  the  amount  of  sugar  in  the  urine  of  diabetics  varies  at  different 
hours  of  the  day,  and  also  under  the  influence  of  diet,  it  is  well  to 
obtain  a  specimen  of  .the  twenty-four-hour  urine  for  examination,  or 
else  get  several  specimens  voided  at  intervals  during  the  day. 

(a)    trommer's  test. 

To  the  filtered  urine  in  a  test  tube  add  one-third  its  volume  of 
potassium  hydrate  and  a  few  drops  of  a  10  per  cent  solution  of  copper 
sulphate.  Heat  the  upper  part  of  the  resulting  blue  fluid  carefully  until 
it  boils.  If  sugar  be  present  a  yellow  or  red,  fine  granular  precipi- 
tate of  cuprous  oxide  will  be  slowly  deposited.  Reduction  taking 
place  before  the  boiling  point  is  reached  is  the  only  one  that  is  character- 
istic of  grape-sugar;  deposits  occurring  after  the  fluid  has  cooled  are 
not  significant. 

This  test  may  give  rise  to  errors  because  other  urinary  constituents 
such  as  uric  acid,  and  especially  creatinin,  possess  the  same 
reducing  power  as  glucose.  [In  my  opinion  the  most  reliable  copper 
test  is  the  glycerine- cupric,  which  is  performed  as  follows:  A  few 
drops  of  a  solution  containing  28  grains  of  copper  sulphate  to  an  ounce 
of  glycerine  are  added  to  a  drachm  of  potassium  hydrate  in  a  test  tube. 
The  mixture  is  boiled  and  urine  added  drop  by  drop.  If  grape  sugar 
be  present  cuprous  oxide  will  be  thrown  out  as  in  Trommer's  test.] 

(b)    bottger's   bismuth  test. 

This  test  depends  upon  the  property  of  grape-sugar  to  reduce 
bismuth  in  the  presence  of  an  alkali.  The  suspected  urine  is  made 
strongly  alkaline  with  potassium  hydrate,  as  much  bismuth  sub- 
nitrate  as  can  be  taken  up  on  the  tip  of  a  pen-knife  added,  and  the 


62  CHEMICAL,    PHYSICAL,    AND    MICROSCOPIC   EXAMINATION. 

mixture  then  boiled.  In  the  presence  of  grape-sugar  reduction  to 
black  metallic  bismuth  takes  place. 

If  the  urine  is  albuminous  the  albumen  must  be  removed  before  this 
test  is  applied,  because  it  will  form  black  sulphide  of  bismuth,  which 
cannot  be  distinguished  from  the  metallic  form  produced  by  glucose. 

The  urine,  if  acid,  may  be  freed  from  albumen  simply  by  boiling  and 
filtering,  but  if  it  is  neutral  or  alkaline  it  must  be  acidulated  with  acetic 
acid  before  it  is  boiled. 

This  test  is  very  useful  if  a  large  quantity  of  sugar  is  present.  [The 
same  method  of  freeing  the  urine  from  albumen  should  be  used  if  one 
of  the  copper  tests  is  employed.] 

(c)    moore's  test. 

If  saccharine  urine  be  mixed  with  one-third  its  volume  of  concen- 
trated potassium  hydrate  and  boiled  a  few  minutes  it  will  turn  brown. 
Less  than  0.5  per  cent  of  sugar  is  not  shown  by  this  method. 

Approximate  quantitative  estimation  may  be  made  from  the  color 
of  the  boiled  fluid: 

Canary  yellow  signifies .  about  1%  of  Sugar 

Amber  signifies from  1  to  2%  "       " 

Light  brown  signifies about  5%  "       " 

Dark  brown  (non-transparent)  signifies.  .  .  .more  than  5%  " 

(d)      THE    FERMENTATION    TEST. 

This  affords  a  very  good  quantitative  method.  [It  may  be  per- 
formed with  Lohnstein's  or  Einhorn's  saccharometer  (Fig.  88),  the 
latter  being  commonly  used  in  America.  One  gramme  of  com- 
pressed yeast  (or  T\  of  a  cake  of  Fleischmann's  yeast)  is  mixed  with 
10  cc.  of  urine  in  the  graduated  test  tube  and  the  mixture  is  poured 
into  the  bulb  of  the  saccharometer;  the  instrument  is  then  tipped  on 
its  side,  whereupon  the  fluid  flows  into  the  cylinder.  It  is  then  left  for 
twenty-four  hours  in  a  warm  room.  Fermentation  will  be  complete 
at  the  end  of  that  time  and  the  upper  part  of  the  cylinder  will  be  filled 
with  carbonic  acid  gas.  The  percentage  of  sugar  is  read  off  on  the 
graduated  scale  at  the  level  of  the  fluid. 

If  the  urine  contains  more  than  one  per  cent  of  sugar  it  must  be 
diluted  with  water  before  the  test  is  applied.  Dr.  Einhorn  directs 
that  diabetic  urine  having  a  specific  gravity  of  1. 018-1. 022  be  diluted 
twice;  1.02 2-1. 028,  five  times;  1. 028-1 .030  ten  times.    The  percentage 


CHEMICAL    EXAMINATION    OF    THE    URINE. 


63 


of  sugar  in  the  undiluted  urine  is  found  by  multiplying  the  per- 
centage contained  in  the  diluted  specimen  by  the  number  of  times 
it  was  diluted.] 

If  the  urine  is  free  from  albumen  quantitive  estimation  of  sugar  can 
be  made  very  readily  by  polarization.  If  albumen  be  present,  however, 
its  left  rotary  power  will  counteract  or  overcome  the  right  rotary  power 
possessed  by  grape-sugar. 

Turbid  or  very  dark  urine  should  be  treated  with  a  10  per  cent  solu- 
tion of  lead  acetate  and  filtered.  In  examining  the  clear  filtrate  its 
degree  of  dilution  must  be  taken  into  account. 

E.    ACETONE  AND  DIACETIC  ACID. 

These  substances  are  frequently  combined,  a  urine  which  contains 
diacetic  acid  also  containing  acetone.  Acetone  may  be  present,  how- 
ever, when  there  is  no  diacetic  acid.  Diacetic 
acid  is  easily  decomposed  into  acetone  and  car- 
bonic acid. 

Acetonuria  occurs  in  various  febrile  condi- 
tions, in  diabetes  mellitus,  in  gastric  and  intes- 
tinal carcinoma,  in  inanition,  in  autointoxication 
and  chronic  morphinism,  after  the  gastric  crises 
of  tabetics,  in  peritonitis,  and  in  pregnancy  as  a 
sign  of  fcetal  death.  It  indicates  albuminous 
putrefaction,  although  it  may  occur  as  a  physi- 
ologic phenomenon  when  an  excess  of  animal 
food  is  being  taken. 

The  presence  of  diacetic  acid,  or  diaceturia,  is 
always  a  very  unfavorable  prognostic  sign.     It 
occurs  in  diabetes,  prolonged  inanition,  gastric  §|, 
and  intestinal  carcinoma,  and  malignant  scar- 
let fever  and  measles. 

rig.   bS. — Einhorn  s  Sac 

For   the    detection    of    acetone    the    urine  is  charometer. 

mixed  with  a  freshly  made  solution  of  nitroprusside  of  potassium  and 
sodium  hydrate  added  until  it  becomes  alkaline.  Acetic  acid  is  then 
added,  whereupon,  if  acetone  be  present,  a  purple  or  red  color 
develops. 

For  the  detection  of  diacetic  acid  a  few  drops  of  ferric  chloride  solution 
are  added  to  the  urine;  if  a  phosphatic  deposit  is  thrown  down  the  mix- 
ture is  filtered  and  more  ferric  chloride  added.     In  the  presence  of 


64  CHEMICAL,    PHYSICAL,    AND    MICROSCOPIC    EXAMINATION. 

diacetic  acid  a  deep  red  color  develops,  which  disappears  upon  the  addition 
of  sulphuric  acid.  Antipyrin,  salicylic  and  carbolic  acid  give  a  similar 
reaction  with  iron  chloride. 

F.    BILE-PIGMENT. 

During  an  attack  of  jaundice  bile-pigment  is  excreted  in  the  urine.  If 
it  be  present  in  large  quantity,  it  can  be  detected  with  the  naked  eye, 
the  urine  having  a  greenish-brown  color  and  a  green  foam  forming  when 
it  is  shaken.  Similarly  colored  urine  due  to  the  ingestion  of  rhubarb  and 
senna  is  distinguished  from  bile-stained  urine  by  the  fact  that  it  produces 
no  yellowr  foam  and  is  turned  red  by  the  addition  of  sodium  hydrate. 

The  primary  bile-pigment  present  in  urine  is  bilirubin,  from  which  are 
formed  by  oxidation  biliverdin,  biliprasin,  and  bilifuchsin. 

For  the  detection  of  bile- pigment  the  suspected  urine  is  poured  upon  a 
layer  of  fuming  nitric  acid  (Gmelin's  Test).  At  the  line  of  contact  a 
colored  ring  is  formed  which  changes  from  green  to  violet,  then  to  red, 
and  finally  to  yellow. 

According  to  Rbsenbach,  the  test  can  be  performed  by  putting  a 
drop  of  urine  upon  a  filter  paper  and  allowing  a  drop  of  nitric  acid  to  fall 
upon  it;  when  the  two  fluids  meet  the  above  described  play  of  colors 
occurs. 

G.    LIPURIA  AND  CHYLURIA. 

Fat  may  be  mixed  with  the  urine  mechanically  (  from  bougies,  specula 
etc.,)  or  it  may  occur  as  the  result  of  a  diet  rich  in  fats.  The  urine  is 
turbid,  grayish  white,  and  under  the  microscope  shows  a  large  number 
of  fat-corpuscles. 

In  chyluria  the  urine  has  a  milky  appearance  and  contains  albumen  as 
well  as  fat. 

To  detect  fat  in  the  urine  add  potassium  hydrate  and  shake  with 
ether;  the  cloudiness  disappears,  or  at  least  becomes  less.  If  a  drop  of 
the  mixture  be  evaporated  upon  a  piece  of  white  paper,  it  leaves  a 
greasy  spot  which  does  not  disappear  upon  being  heated. 

H.    HYDROTHIONURIA. 

Sulphuretted  hydrogen  is  found  in  fresh  urine  in  purulent  cystitis,  in 
pyelitis,  in  cases  where  a  communication  exists  between  the  bladder 
and  bowel,  and  also  very  rarely  when  accumulation  of  gas  occurs  in 
the  rectum. 


CHEMICAL    EXAMINATION    OF    THE    URINE.  65 

It  is  easily  recognized  by  its  odor.  To  detect  it,  acidulate  the  urine 
carefully  and  close  the  bottle  containing  it  with  a  cork  to  which  is 
attached  a  piece  of  paper  previously  wet  with  acetate  of  lead  solution; 
if  sulphuretted  hydrogen  be  present  the  paper  will  turn  black. 

Pneumaturia,  that  is,  a  condition  in  which  free  gas  escapes  with  the 
urine  and  causes  a  blowing  sound,  has  been  observed  when  diabetic 
urine  has  undergone  decomposition  in  the  bladder. 

I.    INDICAN. 

How  far  the  presence  of  an  increased  quantity  of  indican  in  the  urine 
is  of  diagnostic  value  has  not  yet  been  determined.  We  know,  however, 
that  an  increase  very  often  occurs  in  putrid  suppurative  conditions,  in 
intestinal  obstruction,  and  especially  in  gastric  and  intestinal  diseases 
associated  with  decomposition  of  food. 

For  the  detection  of  indican  10  cc.  (about  3  fluid  drachms)  of  urine, 
previously  freed  from  albumen  by  boiling  and  filtration,  are  mixed  with 
2  cc.  (|  fluid  drachm)  of  chloroform  and  10  cc.  (about  3  fluid  drachms) 
of  concentrated  hydrochloric  acid,  and  1  or  2  drops  of  a  fresh  concen- 
trated aqueous  solution  of  chlorinated  lime  added  and  the  mixture 
thoroughly  shaken.  If  an  excess  of  indican  be  present  the  chloroform 
will  settle  to  the  bottom  of  the  tube  as  a  blue- colored  fluid. 

J.    BLOOD. 

If  to  urine  containing  blood,  about  one-third  its  volume  of  potassium- 
hydrate  be  added  and  the  mixture  boiled,  earthy  phosphates  colored 
with  blood  pigment  will  be  precipitated;  in  the  absence  of  blood  this 
precipitate  will  be  white  or  yellowish  white. 

[Haemoglobin  may  also  be  detected  by  adding  a  few  drops  of  freshly 
prepared  tincture  of  guaiacum  to  the  urine,  together  with  a  like 
quantity  of  ozonized  ether,  and  shaking  the  mixture  thoroughly ;  if  haemo- 
globin be  present,  the  ether,  which  rises  to  the  top  of  the  tube,  will 
assume  a  blue  color.] 

K.    PROPERTIES  OF  THE  URINE  AFTER  THE  INGESTION 
OF  CERTAIN  DRUGS. 

Urine  containing  phenol,  naphthalin,  and  salol,  the  last  of  which  is 
decomposed  into  salicylic  and  carbolic  acid,  is  greenish-brown  in  color, 
and  becomes  darker  after  being  exposed  to  the  air.  The  urine  possesses 
similar  characteristics  after  the  use  of  uva  ursa  and  preparations  of  tar. 

Balsam  of  copaiba  causes  it  to  assume  a  red  color  upon  the  addition 

5 


66  CHEMICAL,    PHYSICAL,    AND    MICROSCOPIC    EXAMINATION. 

of  hydrochloric  acid.  After  the  internal  and  external  use  of  this  drug, 
and  also  of  sandal-oil  and  styrax,  the  urine  contains  resinous  acids, 
which  upon  being  subjected  to  heat  or  brought  into  contact  with  nitric 
acid,  produce  a  turbidity  resembling  that  due  to  albumen.  It  may  be 
distinguished  from  the  latter  by  adding  to  the  urine  twice  its  own 
volume  of  alcohol,  whereupon  all  turbidity  immediately  disappears. 
If  the  heat  test  is  used  do  not  add  the  alcohol  until  the  urine  has  cooled ; 
if  the  nitric  acid  test  is  employed  an  excess  of  acid  must  not  be  present, 
because  it  will  cause  decomposition  of  the  alcohol  with  violent  liber- 
ation of  gas. 

After  the  ingestion  of  turpentine  the  urine  has  the  odor  of  violets. 

The  salts  of  iodine  and  bromine  are  detected  by  adding  a  few  drops  of 
hydrochloric  acid  and  chloroform  to  the  urine  and  shaking  it  well ;  the 
chloroform,  which  sinks  to  the  bottom  of  the  tube,  is  colored  violet- 
red  by  iodine  and  brownish  yellow  by  bromine. 

The  presence  of  potassium  chlorate  is  determined  by  acidulating  the 
urine  with  hydrochloric  acid  and  adding  a  fresh  solution  of  potassium 
iodide  in  starch- water.  Upon  heating  the  mixture,  it  will  assume  a 
blue  color,  which  is  due  to  the  formation  of  iodized  starch. 

Salicylic  acid  gives  a  violet  color  with  ferric  chloride. 

Antipyrin  gives  a  red  color  with  ferric  chloride. 

Santonin  colors  the  urine  bright  yellow;  upon  the  addition  of 
potassium  hydrate  it  becomes  scarlet  red. 

Rhubarb  and  senna  also  give  a  red  color  with  potassium  hydrate,  but 
it  is  permanent,  while  that  produced  by  santonin  soon  disappears.  If 
baryta  water  be  added  a  red  precipitate  is  produced  by  senna  and  rhu- 
barb, whereas  if  santonin  be  present  the  fluid  will  be  colored  red. 

A  test  requiring  more  precision,  but  yet  one  which  is  at  times  most 
important,  is  that  for  mercury.  To  300  cc.  (10  fluid  ounces)  of  urine 
a  small  quantity  of  sodium  hydrate  and  sugar  is  added  and  the  mixture 
heated  to  the  boiling  point.  The  phosphates,  carrying  the  mercury 
with  them,  will  be  precipitated.  The  supernatant  fluid  is  drawn  off  and 
the  precipitate  dissolved  in  hydrochloric  acid.  The  resulting  solution 
is  boiled  over  a  slow  fire  for  an  hour  and  a  half,  during  which  time  a 
copper  wire,  previously  heated  to  a  glowing  heat,  is  suspended  in  it. 
The  wire  is  then  taken  out,  boiled  in  a  very  weak  solution  of  sodium 
hydrate,  and  dried  between  two  filter  papers.  If  the  wire  now  be  heated 
in  a  fused  glass  tube,  the  mercury  will  be  sublimed  and  deposited  in  the 
form  of  minute  globules  in  the  upper  and  cooler  part  of  the  tube. 


CHEMICAL    EXAMINATION    OF    THE    URINE. 


67 


For  the  purpose  of  quickly  securing  practical  information  at  the  bed- 
side the  following  urine-examination  is  recommended: 

I.  Turbid  urine  is  put  into  a  test  tube  and  the  upper  portion  boiled. 
Three  possibilities  exist: 

1.  The  turbidity  may  disappear;  if  so  it  is  due  to  urates.    " 

2.  The  turbidity  may  become  more  intense  in  the  boiled  portion;  in 
this  case  we  have  to  do  with  pyuria,  phosphaturia,  or  carbonaturia.  Dis- 
tinction between  the  three  is  made  by  the  addition  of  a  few  drops  of 
acetic  acid.  If  the  increased  turbidity  be  due  to  pyuria  it  remains, 
whereas  if  caused  by  phosphaturia  or  carbonaturia  it  disappears 
entirely,  the  urine  becoming  perfectly  clear.  Turbidity  due  to  car- 
bonates clears  up  with  evolution  of  gas,  but  when  produced  by 
phosphates  no  such  phenomenon  occurs. 

3.  The  turbidity  may  remain  unchanged,  in  which  case  it  is  to  be 
attributed  to  the  presence  of  mucus  (mucinuria),  semen  (spermaturia), 
or  bacteria  (bacteriuria).  These  conditions  are  to  be  differentiated 
by  the  microscope. 

The  following  table  may  serve  to  impress  these  differences  upon  the 
mind. 

If  the  upper  portion  of  the  turbid  urine  be  boiled 


The  turbidity 
disappears 


The  turbidity  is  increased 


The  turbidity  is 
unchanged 


in  the  boiled  portion. 

Urates. 

If      it      remains 

after  the  addition 

of  acetic  acid, 

Pyuria. 

If    it    disappears 

upon  the  addition 

of  acetic  acid, 

Phosphaturia. 

Carbonaturia. 

Mucinuria. 
Bacteriuria. 
Spermaturia. 

II.  Clear  urine  is  examined  in  the  same  way,  the  upper  portion  in 
the  test  tube  being  boiled. 

1.  If  turbidity  arise  it  is  due  either  to  albumen  or  phosphates.  A 
drop  of  acetic  acid  serves  to  differentiate:  if  the  turbidity  is  caused  by 
albumen  it  remains;  if  produced  by  phosphates  it  disappears. 

2.  If  the  urine  remains  clear,  then  a  drop  of  acetic  acid  must  be 
added;  if  it  still  remains  clear,  it  is  free  from  albumen;  if  cloudiness 
appears,  then  albumen  is  present.  The  albumen  was  combined  with 
an  alkali  and  could  not  be  brought  forth  by  heat,  but  the  addition  of 


68  CHEMICAL,    PHYSICAL,    AND    MICROSCOPIC    EXAMINATION. 

acetic  acid  gave  rise  to  the  formation  of  an  alkaline  acetate  with 
liberation  of  the  albumen.  Such  a  condition  occurs  only  when  the 
urine  is  alkaline. 

The  following  table  may  be  used  for  reference: 

If  the  upper  portion  of  clear  urine  be  boiled 
The  urine  becomes  turbid  in  the  boiled  portion  The  urine  remains  clear 

~        '.     i  T.     '.       i 

If  the  turbidity  remains  If  the  turbidity  disap  If  it  becomes  turbid 

after    the    addition    of  pears  upon  the  addition  j       upon  the  addition  of 

acetic  acid,                          of  acetic  acid,  acetic  acid, 

Albuminuria.                          Phosphaturia.  Albuminuria. 


3.    MICROSCOPIC  EXAMINATION  OF  THE  URINE. 

In  every  case  chemical  examination  of  the  urine  should  be  supple- 
mented by  microscopic  examination.  Even  though  the  urine  be  per- 
fectly clear,  this  should  be  done;  for  frequently  things  are  revealed  by 
the  microscope  which  cannot  be  seen  macroscopically,  nor  even  be  sus- 
pected from  the  physical  characteristics  of  the  urine.  For  an  exact 
diagnosis  it  is  indispensable  that  all  the  constituents  of  the  urine  be 
examined  under  the  microscope. 

Formerly  it  was  customary  to  allow  the  urine  to  settle  in  a  conical  glass 
and  then  examine  the  sediment.  This  method  is  no  longer  in  vogue. 
We  know  that  bacteria  develop  in  urine  which  stands  for  any  length  of 
time,  and  that  the  urine  itself  undergoes  changes.  Therefore  it  is  desir- 
able to  examine  it  as  soon  as  possible  after  it  is  voided.  For  this  purpose 
the  centrifuge  is  employed ;  by  its  use  the  sediment  of  the  urine  is  pre- 
pared for  examination  in  a  few  minutes.  We  differentiate  between 
the  organized  and  unorganized  elements  of  the  sediment. 

A.    ORGANIZED  SEDIMENT. 

i.  Blood-corpuscles.  The  number  of  red  blood-corpuscles,  or 
erythrocytes,  vary  with  the  severity  of  the  haemorrhage.  Generally  they 
occur  singly,  forming  rouleaux  only  when  very  severe  haemorrhage  has 
occurred.  In  recent  haemorrhages  they  appear  as  small  round  discs  with 
a  light  red  central  shadow  (Fig.  89  a) ;  when  lying  on  their  edges,  they 
are  biconcave.  (Fig.  89).  Very  soon,  especially  in  concentrated  acid 
urine,  they  shrink  owing  to  abstraction  of  water  (Fig.  89  b),  and  finally 


MICROSCOPIC    EXAMINATION    OF    THE    URINE. 


69 


assume  a  stellate  appearence  (Fig.  89  c).  In  dilute  and  alkaline  urine 
they  become  swollen,  lose  their  color,  and  appear  in  the  form  of 
bright  rings  (Fig.  89  d).  Red  blood-corpuscles  which  have  entirely 
given  up  their  coloring  matter,  are  known  as  "blood  shadows" 
(Blutschatten).  They  have  a  faint  circular  outline  and  are  generally 
smaller  than  the  blood-cells  from  which  they  were  derived  (Fig.  90). 
They  show  that  the  blood-cells  have  been  in  the  urine  for  some  time, 
and  if  the  specimen  of  urine  be  fresh,  that  the  haemorrhage  took  place 
sometime  before. 

Minute  spherical  bodies,  which  in  contrast  to  the  blood-shadows  have 
retained  the  coloring  matter  of  the  blood,  are  called  microcytes. 

White  blood-corpuscles  (leucocytes),  pus-corpuscles,  lymph-corpus- 


®  _  £y    £.  © 

5«® 


=s> 


© 


@@~ 


© 


—  a 


i    § 
d-\-0    ^       0  ®  ®  SS 

\    OO  ©    |§  ®    ~®^w 

Fig.  89. — a,  Blood-corpuscles  showing  depressions  in  center.  b  and  c,  shrunken 
corpuscles,     d,  swollen  corpuscles. 

cles,  and  mucus-corpuscles  have  a  round  form,  but  change  it  by  means 
of  amoeboid  movements.  When  perfectly  fresh  they  do  not  show  a 
nucleus,  but  have  a  granular  appearence  (Fig.  91).  In  time,  and  also 
upon  the  addition  of  acetic  acid,  they  develop  one  to  four  nuclei  from 
their  granular  protoplasm,  which  when  highly  magnified  show  nucleoli 
in  their  interior. 

Leucocytes  may  be  mistaken  for  small  round  epithelial  cells.  To 
differentiate  between  the  two  let  a  drop  of  Gram's  solution  run  under 
the  cover-glass;  the  leucocytes  will  be  colored  an  intense  mahogany- 
brown,  while  the  epithelial  cells  will  be  stained  light  yellow.  Mucus 
and  lymph-corpuscles  cannot  be  differentiated  under  the  microscope. 


7o 


CHEMICAL,    PHYSICAL,    AND    MICROSCOPIC    EXAMINATION. 


2.  Epithelium.  Various  forms  of  epithelium  are  found  in  the 
urine.  The  epithelium  from  the  renal  tubules,-  from  the  pelvis  of  the 
kidney,  from  the  bladder  and  urethra,  from  the  prostate  gland,  from 
the  vagina — all  these  are  found  occasionally  in  the  urine.  It  has  long 
been  attempted  to  locate  the  source  of  the  epithelium  by  its  form. 


rPOO  ©         O 


a<r: 


Fig.  90. — Blood- 
shadows  and 
microcytes. 


Fig.  91. — Leucocytes. 


Figures  92,  93  and  94  show  the  various  forms  of  epithelium: 
From  these  illustrations  it  will  be  seen  that  the  epithelium  of  the 
different  parts  of  the  genito-urinary  tract  is  very  much  alike.     Thus, 
polygonal  cells,  which  are  found  very  frequently  in  the  pelvis  of  the  kid- 


FiG.  92. — Vesical  epithelium. — (Greene.) 

ney,  also  occur  in  the  deep  layers  of  the  urethra  and  in  the  prostate. 
The  recognition  of  different  kinds  of  epithelia  by  their  form  or  shape  is 
often  impossible,  and  so  in  reply  to  the  oft  repeated  assertion  that  the 
form  of  the  epithelium  enables  us  to  tell  the  site  of  the  affection,  we 


MICROSCOPIC    EXAMINATION    OF    THE    URINE. 


71 


must  say  with  Eichhorst  and  Bizzozero,  that  this  is  possible  only  in  the 
rarest  cases.  The  sole  exception  to  be  made  is  that  of  the  renal  epithe- 
lium, which  unfortunately  is  not  often  found,  being  greatly  outnumbered 
by  other  varieties.  These  sharply  outlined,  round  cells  with  large  nuclei 
are  characteristic,  but  they  may  be  easily  confused  with  leucocytes. 
Their  size  is  an  important  point  of  distinction,  they  being  larger  than  the 
leucocytes. 

3.     Urinary  Casts.     The  great  diagnostic  significance  of  urinary 
casts  is  generally  known.     Their  origin  has  been  explained  in  various 


Fig.  93. — Various  forms  of  renal  cells,  including  "  compound 
granule  cells." — (Greene.) 

ways.  According  to  one  theory,  as  a  result  of  disease  of  the  glomeruli 
the  albuminous  constituents  of  the  blood  filter  through  into  the  renal 
tubules  and  become  moulded  into  their  shape  (hyaline  casts).  If 
epithelium  from  the  tubules,  or  blood  cells,  or  any  other  substances 
become  united  with  these  cylinders,  then  epithelial  or  blood  casts,  etc., 
are  formed.  Another  view  is  that  all  casts,  hyaline  included,  are  com- 
posed of  metamorphosed  epithelium. 

The  following  varieties  of  casts  are  met  with  in  urinary  sediment : 
(a)  Hyaline  Casts.     These  are  of  homogeneous  structure,  translu- 
cent, and  so  pale  that  they  can  hardly  be  distinguished  from  their 


72 


CHEMICAL,    PHYSICAL,    AND    MICROSCOPIC    EXAMINATION. 


surrounding    medium.     When    searching    for  them   the   microscopic 
field   should   be   darkened    (Fig.   95). 

(b)  Granular  Casts.    These  are  of  varying  length  and  breadth,  are 


Fig.  04. — a.  Epithelium  from  the  renal  pelvis;  b,  vaginal  epithelium. — (Greene.) 

yellowish  white  or  gray  in  color,  sharply  outlined,  and  often  indented. 
They  are  rounded  at  the  ends.  The  granules  may  be  distributed 
throughout  the  entire  cast,  or  scattered  only  here  and  there  so  that  it  is 


Fig.  95. — a,  Hyaline  cast,     b,  Hyaline  cast  studied  with  a  few  leuco- 
cytes,    c,  Hyaline  cast  studied  with  renal  epithelium. 

partly  hyaline.     Isolated  leucocytes  are  now  and  then  observed  in 
different  portions  of  the  cast  (Fig.  96). 


MICROSCOPIC    EXAMINATION    OF    THE    URINE. 


73 


(c)  Epithelial,  Leucocyte,  and  Blood  Casts.  These  have  a  very 
characteristic  appearance.  Free  blood-corpuscles,  mostly  the  so- 
called  "  blood-shadows, "  lie  close  to  the  cast;  the  epithelial  cast  shows 
epithelium  only  in  its  upper  portion,  being  granular  below  (Fig.  97  a, 
b,  and  c). 

(d)  Waxy  or  Amyloid  Casts.  This  variety  is  characterized  by  its 
strong  refractive  power  whereby  it  is  given  a  shiny,  wax  like  appearance. 


Fig.  96. — Granular  cast. 


Fis.  97a. — Blood  cast. 


Fig.  976. — Leucocyte  cast. 


Fig.  gjd. — Cast  of  acid  sodium 
urate. —  (v.  Jaksch.) 


Fig.  98  — Waxy  cast. — (Tyson.) 

These  casts  are  often  large  and  broad  and  show  clefts  and  indentations. 
Frequently  shining,  irregularly  shaped  flakes  are  seen  near  them. 
Some,  but  not  all,  waxy  casts  give  the  amyloid  reaction,  that  is,  they 
stain  red  with  methyl  violet.  For  an  explanation  of  their  origin  it  is 
necessary  to  assume  that  the  albuminous  substance  originally  entering 
into  their  composition  undergoes  amyloid  degeneration  (Fig.  98). 


74  CHEMICAL,    PHYSICAL,    AND    MICROSCOPIC    EXAMINATION. 

(e)  Fatty  Casts.  These  are  casts  containing  globules  of  oil.  In 
addition  to  droplets  of  fat  needle-shaped  crystals  of  fatty  acids  are 
sometimes  observed. 

From  these  varieties  of  true  casts,  the  so-called  false  casts  composed  of 
urates  and  micrococci  must  be  differentiated,  as  must  also  cylindroids. 

Figure  97  d  shows  a  cast-like  structure  composed  of  acid  urate  of 
sodium.  Such  masses  are  easily  distinguished  from  granular  casts, 
because  they  shrivel  up  when  brought  in  contact  with  acetic  acid. 

Crystals  of  uric  acid  and  calcium  oxalate  may  be  precipitated  upon 
cylindrical  coagula  of  mucus,  which  are  then  designated  as  uric  acid 
casts  or  oxalate  of  calcium  casts,  as  the  case  may  be. 

Closely  resembling  these  forms  are  the  micrococcic  cylinders,  which 
consist  of  aggregations  of  micrococci.  They  resist  both  potassium 
hydrate  and  nitric  acid. 

The  mucoid  structures  called  cylindroids  are  likely  to  be  mistaken 


Fig.  99. — Cylindroid. 

for  hyaline  casts.  They  are  generally  characterized  by  their  enormous 
length,  often  extending  over  several  microscopic  fields.  Figure  99  shows 
such  a  structure  upon  which  an  epithelial  cell  and  a  few  leucocytes 
have  been  deposited. 

4.  Microorganisms.  Freshly  voided  urine  is  free  from  micro- 
organisms, and  may  be  considered  sterile.  If  it  contain  microorgan- 
isms their  presence  is  due  to  some  pathologic  condition.  For  these 
reasons  the  necessity  of  examining  fresh  urine  with  the  aid  of  the  centri- 
fuge becomes  apparent. 

Bacteriuria  is  a  name  applied  to  a  mycotic  affection  of  the  bladder 
or  kidneys  in  which  the  urine  contains  microorganisms  without  an 
associated  presence  of  pus.  This  is  exceptional  for  the  two  are.  almost 
always  associated. 


MICROSCOPIC    EXAMINATION    OF    THE    URINE. 


75 


It  must  also  be  borne  in  mind  that  in  a  great  variety  of  systemic 
diseases  bacteria  are  excreted  in  the  urine  without  producing  any 
lesions  of  the  urinary  organs. 

Blastomycetes,  hyphomycetes,  and  schizomycetes  are  found  in  the 
urine  Some  of  them  are  met  with  only  after  the  urine  has  stood  a  long 
time,  but  as  it  is  not  always  possible  to  examine  the  urine  when  it  is 
fresh,  it  is  necessary  to  know  the  appearance  of  these  organisms. 

Of  the  blastomycetes,  the  yeast-cells  or  saccharomycctes  are  most 
common,  especially  in  diabetic  urine.  They  appear  as  small  round 
vesicles  connected  with  one  another  like  a  string  of  pearls,  and  gener- 


Fig.   ioo. — a,  Micrococci  in  short  chains  and  groups,     b,  Sarcinae.     c,  Fungi 
from  acid  fermentation,    d ,  Yeast  cells  from  diabetic  urine,    e,  Mycelium. 

ally  arranged  in  clusters.  On  some  of  the  cells  germination  maybe  seen 
(Fig.  iooc).  Besides  these  there  are  vesicular  blastomycetes  which 
closely  resemble  yeast  fungi,  only  they  are  smaller  (Fig.  ioo  d). 

That  they  may  not  be  confounded  with  other  cells  (leucocytes, 
microcytes)  a  drop  of  acetic  acid  should  be  allowed  to  flow  under  the 
cover  glass:  blastomycetes  remain  unchanged,  while  the  nuclei  of 
leucocytes  come  out  with  great  distinctness. 

Hyphomycetes  are  found  in  the  urine  only  when  it  has  stood  a  long 
time.  Penicillium  glaucum  which  is  often  present  may  be  easily 
recognized  by  its  tuft-like  or  arborescent  branches.  Outside  the 
retiuclum,  or  mycelium,  spores  are  seen. 


76 


CHEMICAL,    PHYSICAL,    AND    MICROSCOPIC    EXAMINATION. 


We  shall  have  very  little  to  say  concerning  the  schizomycetcs,  as  the 
significance  of  their  presence  in  the  urine  has  not  been  clearly  deter- 
mined. By  some  one  organism  has  been  deemed  pathogenic,  by  others 
another.  Many  of  them  are  merely  excreted  in  the  urine,  having  their 
origin  in  distant  parts  of  the  body  and  passing  through  the  kidneys  into 
the  bladder  without  causing  disease  of  the  latter  organ.  We  will  not 
discuss  this  question  here,  but  will  proceed  to  enumerate  the  principal 
forms  which  are  met  with. 

The  micrococcus  ureas  appears  in  the  form  of  long,  comparativelv 


Y-poQK^^j^) 


Fig.  ioi. — Micrococcus 
ureae. — (v.  Taksch.) 


Fig.  102. — Bacterium  urea;. 


Fig.   103. — Micrococcus  ureas  arranged 
in  masses  of  zooglea. 


Fig.  104. — Leptothrix. — (Peyer.) 


large  cocci  arranged  in  chains  (Fig.  101).  It  decomposes  urea  into 
carbonic  acid  and  ammonia.  There  is  also  a  bacterium  ureae  which 
possesses  the  same  property  of  decomposing  the  urine  (Fig.  102).  Both 
these  varieties  occur  as  masses  of  zooglea  (Fig.  103).  Furthermore  we 
recognize  a  kind  called  vibriones,  which  represent  a  union  of  several 
rodlets.  When  highly  magnified  their  articulations  may  be  discerned. 
Their  movement  is  slow  and  sluggish.  A  longer  succession  of  bacteria 
is  known  as  leptothrix  (Fig.  104). 

Rarely  the  packet-like  cocci  called  sarcinae  are  found  (Fig.  100  b) 


MICROSCOPIC    EXAMINATION    OF    THE    URINE. 


:; 


Among  the  other  organisms  which  are  found  may  be  mentioned  bac- 
terium coli,  proteus,  staphylococcus  pyogenes  albus  and  aureus,  gon- 
ococci,  tubercle  bacilli,  the  bacilli  of  anthrax,  typhoid  and  relapsing 
fever,  glanders,  and  finallv  the  smegma  bacillus.  This  number  by  no 
means  completes  the  list. 


Fig.  io^. — Trichomonas  vaginalis. 


Fig.  106. — Filaria  sanguinis. 


fe^ 


& 


Fig.  io-. — Ova  of  the  distomum  hematobium. — (Uitzmann.) 

Animal  Parasites.  Trichomonas  vaginahs  is  occasionally  found 
in  the  urine  of  women  suffering  from  leucorrhcea  (Fig.  105).  Morerarelv 
the  oxyuris  vermicularis,  ascaris  lumbricoides,  and  filaria  sanguinis  are 
found  i,Fig.  106). 


78 


CHEMICAL,    PHYSICAL,    AND    MICROSCOPIC    EXAMINATION. 


Of  greater  importance  is  the  distoma  haematobium,  a  parasite  which 
is  prevalent  in  Egypt,  Brazil,  and  other  tropical  countries,  and  which 
causes  vesical  and  renal  haemorrhage.  The  spores  of  this  para- 
site (Fig.  107)  have  an  oval  form  and  are  rounded  at  one  end,  the  other 
end  tapering  into  a  short  spine. 

Equally  important  is  the  occurrence  of  hydatid  cysts,  which  may  reach 
the  size  of  a  walnut.     If  they  are  sterile  they  consist  of  a  structureless 


A.- 


Fig.  108. — Echinococcus.     A  and  B,  head  of  the  parasites.     C,  Hooklets. 


*« 


.-J 


7- a 


Fig.  109. — a,  Acid  sodium  urate,     b,  Uric  acid. 

membrane  containing  fluid.  Frequently,  however,  the  bladder  con- 
tains fecundated  sacs  (Fig.  108).  The  head  of  the  parasite  (A  and  B), 
and  the  hooklets  (C)  floating  free  in  the  urine  should  be  looked  for. 

B.     UNORGANIZED  SEDIMENTS. 

The  unorganized  sediments  are  classified  according  to  the  reaction 
of  the  urine  in  which  they  occur. 

THE   SEDIMENTS   OF   ACID  URINE. 

i .   Acid  urate  of  sodium  and  more  rarely  the  corresponding  potassium 
salt.     They  occur  as  moss-like  masses  of  amorphous  granules  varying 


MICROSCOPIC    EXAMINATION    OF    THE    URINE.  79 

in  color  from  gray  to  bright  yellow  or  brown  (Fig.  109  a).  If  a  drop  of 
hydrochloric  acid  be  added  to  them  they  are  decomposed  and  in  course 
of  half  an  hour  precipitate  crystals  of  uric  acid. 

2.     Uric  acid,  which  forms  gray,  yellow,  or  brown  crystals  of  various 
shapes,  such  as  rhomboid,  spindle,  cylindrical,  whetstone-shape,  and 


Fig.  1 10. —Calcium  oxalate — (Greene.) 


Fig.  hi. — Cystin. 


also,  rosettes  which  are  formed  by  a  combination  of  the  others  (109  b). 
Rarely  uric  acid  occurs  in  the  form  of  irregular  crystalline  spicules  which 
Ultzmann  has  associated  with  the  development  of  renal  stone. 
Micro-chemical  test:  Run  a  drop  of  potassium  hydrate  under  the 


8o 


CHEMICAL,    PHYSICAL,    AND    MICROSCOPIC    EXAMINATION. 


cover-glass  and  the  uric  acid  crystals  disappear,  being  converted  into 
soluble  potassium  hydrate.  If  hydrochloric  acid  now  be  added  re- 
crystallization  of  uric  acid  begins. 

3.  Calcium  oxalate  appears  in  the  form  of  small  glistening  octa- 
hedrals,  which  when  seen  from  above  look  like  envelopes  [or  squares 
crossed  diagonally  by  two  lines].  Less  commonly  prismatic  and  hour- 
glass forms  are  seen  [the  so-called  dumb-bell  crystals].  Calcium  oxalate 
is  soluble  in  hydrochloric  acid,  insoluble  in  acetic  acid  (Fig.  no). . 

4.  Cystin.  Colorless,  irregular,  six-sided  crystals,  soluble  in 
hydrochloric  acid,  alkalies  and  ammonia.     (Fig.  in.) 


Fig.  112. — Leucin  and  tyrosin.     a.a,  leucin  balls;  b.b,  tvrosin 
sheaves;  c,  double  balls  of  ammonium  urate. — (Holland.) 


5.  Xanthin.  A  very  rare  sediment,  occurring  as  regular  hexagonal 
laminae.     It  is  soluble  in  ammonia  and  hydrochloric  acid. 

Leucin  and  tyrosin.  The  latter  forms  fine,  colorless,  shining  needles, 
which  are  readily  soluble  in  alkalies  (Fig.  112).  Leucin  occurs  as  yellow 
spheres  having  concentric  striations.  It  is  soluble  in  acids  and  alkalies 
(Fig.  112). 

[These  substances  are  the  products  of  rapid  retrograde  metamorphosis, 
such  as  occurs  in  acute  yellow  atrophy  of  the  liver  and  phosphorus 
poisoning.  They  are  said  to  occur  in  severe  cases  of  typhoid  fever, 
small  pox,  and  pyaemia.] 

A  sediment  of  rather  infrequent  occurrence  is  sulphate  of  calcium, 
which  appears  as  long,  colorless  needles  or  as  lamellae  with  sharply  trim- 


MICROSCOPIC    EXAMINATION    OF    THE    URINE.  51 

med  ends.     It  is  somewhat  similar  to  neutral  phosphate  of  calcium 
(Fig.  113J. 

8.     Indigo.     Blue  lamellae  or  black  scales,  rhomboid  in  shape,  with 
tapering  ends. 

THE   SEDIMENTS   OF  ALKALINE   URINE. 

i.     Crystalline  neutral  phosphate  of  calcium  (Fig.  114  b).     These 
crystals  cannot  be  produced  artificially  by  the  ingestion  of  alkalies,  and 


Fig.  113. — Crystals  of  calcium  sulphate. — (Van  Nuys.1 


Fig.  114. — a,  Finely  granular  carbonate  of  calcium; 
b,  crystalline  neutral  phosphate  of  calcium. 

consequently  are  characteristic  of  essential  phosphaturia.  Their  pres- 
ence excludes  the  possibility  of  ammoniacal  decomposition  of  the  urine, 
for  as  soon  as  the  minutest  quantity  of  ammonia  is  added  to  them 
they  disappear. 


82 


CHEMICAL,    PHYSICAL,    AND    MICROSCOPIC    EXAMINATION. 


2.  Crystalline  phosphate  of  magnesium,  which  is  much  like  the  am- 
monio-magnesium  phosphate  shown  in  Fig.  116,  although  the  crystals 
are  longer  than  they  are  broad.  They  are  still  further  differentiated 
by  the  fact  that  they  may  occur  irrespective  of  the  presence  of  bacteria, 
with  which  ammonio-magnesium  phosphate  is  always  associated. 


Fig   115. — Carbonate  of  calcium. 


Fig.  116. — The  more  usual  forms 
of  triple  phosphate. — (Holland.) 


Fig.  117. — Stellate  and  feathery  crystals  of  triple  phosphate. — (Harley.) 

3.  Calcium  carbonate,  which  may  be  either  amorphous  or  granular 
crystalline,  the  latter  forming  small,  shining,  mulberry-shaped  granules 
(Figs.  114  and  115). 

4.  Ammonio-magnesium  phosphate,  which  occurs  in  two  forms, 
rhomboid  plates,  the  so-called  coffin-lid  crystals,  and  large  prisms  with 


MICROSCOPIC    EXAMINATION    OF    THE    URINE.  83 

slanting  ends  (Fig.  116).  If  the  crystals  be  precipitated,  serrated, 
cruciform,  or  fern-shaped  structures  will  be  observed  (Fig.  117).  The 
crystals  are  soluble  in  acetic  acid. 

5.  Urate  of  ammonium  is  yellow  or  brown  in  color  the  same  as  all 
urates.  It  forms  needles  with  spherules  on  their  ends,  and  also  double 
globules  having  processes  similar  to  the  rays  of  a  star-fish  (Fig.  118). 

Micro-chemical  test:  The  addition  of  a  drop  of  hydrochloric  acid 
forms  ammonium  chloride  and  liberates  uric  acid.     The  ammonium 


Fig.  118. — Ammonium  urate. — (Greene.) 

crystals  soon  disappear  and  whetstone-shaped  or  rhomboid  crystals 
of  uric  acid  are  formed. 

ACCIDENTAL  CONTAMINATION  OF  THE  URINE. 

During  microscopic  examination  of  urinary  sediment  structures  are 
often  found  which  might  be  mistaken  for  essential  constituents  of  the 
urine,  but  which  are  really  due  to  contamination  of  that  fluid.  It  is 
self-evident  that  it  is  necessary  to  be  familiar  with  their  appearance  in 
order  to  guard  against  errors. 

Among  those  most  frequently  met  with  are  hairs,  fragments  of 
feathers,  animal  and  vegetable  fibers,  both  colored  and  uncolored, 
(wool,  hemp,  silk,  linen),  starch -granules,  fat-globules,  and  air-bubbles. 


84  CHEMICAL,    PHYSICAL,    AND    MICROSCOPIC    EXAMINATION. 

Figure  119  shows  those  most  frequently  encountered.  To  the  left 
is  a  twisted  cotton-fibre,  and  close  beside  it  is  the  barb  of  a  feather.  A 
long,  slender,  cylindrical  silk-fibre  runs  across  the  picture  from  left  to 
right  and  from  above  downwards.     At  the  right  is  a  hemp  fibre  plainly 


Fig.  119. — After  Kratschmer-Senft. 

showing  constrictions.  Of  the  two  crossing  it  the  upper  one  is  a  hair, 
the  lower  one  a  wool-fibre.  The  bodies  seen  in  the  lower  right  hand 
corner  are  starch-granules,  those  above  fat-globules,  and  the  two  to  the 
left  are  air-bubbles. 


ANATOMY  OF  THE  URETHRA.  85 

SPECIAL  PART. 


DISEASES   OF   THE  URETHRA   AND   PENIS. 
ANATOMY. 

(a)    DIVISION. 

Instead  of  adhering  to  the  old  anatomical  division  of  the  urethra  into 
a  penile,  membranous,  and  prostatic  portion,  we  will  divide  it  into  an 
anterior  and  posterior  portion.  The  anterior  part  corresponds  to  the 
penile,  while  the  posterior  includes  both  membranous  and  prostatic  por- 
tions. Some  other  terms  in  use  explain  themselves.  Thus  the  name 
pars  mobilis  is  applied  to  that  portion  which  lies  within  the  penis,  and 
pars  fixa  to  the  remaining  portion.  The  boat  shaped -depression  in  the 
anterior  urethra  is  called  pars  (or  fossa)  navicularis,  and  the  pouch-like 
expansion  at  the  termination  of  the  anterior  portion  the  pars  bulbosa. 
Finally  there  are  the  pars  scrotalis  and  the  pars  perinealis. 

(b)    FORM. 

The  male  urethra  is  shaped  like  an  elongated  S,  having  two  curves, 
the  first  of  which  extends  convexly  forwards  and  upwards,  while  the 
second  is  concave  in  the  same  direction.  The  first  curve  exists  only 
when  the  penis  is  flaccid.  It  begins  at  the  point  where  the  penis  is 
attached  to  the  symphysis  pubis  by  the  suspensory  ligament  (see 
Fig.  120  a).  During  erection,  or  when  the  penis  is  lifted  up,  the  curve 
becomes  entirely  obliterated,  so  that  the  whole  anterior  urethra  down 
to  the  bulb  extends  in  a  straight  line.  From  a  technical  point  of  view 
relating  to  the  introduction  of  instruments  this  anterior  curve  may  be 
entirely  disregarded. 

The  second  curve  which  the  urethra  describes  around  the  sym- 
physis cannot  be  obliterated,  and  is,  therefore,  of  much  greater  import- 
ance surgically  than  the  first.  The  curve  is  equal  to  about  one-third  of 
a  circle  whose  radius  is  6  cm.  (2-f  inches.)  The  summit  of  this  curve 
at  the  internal  orifice  of  the  urethra  lies  about  3  cm.  (ij-  inches)  be- 
hind the  under  half  of  the  posterior  surface  of  the  symphysis  pubis,  and 
its  deepest  part  about  18  mm.  (^  of  an  inch)  below  the  inferior  margin  of 
the  symphysis.     This  curve,  of  which  an  adequate  conception  may  be 


86 


DISEASES    OF    THE    URETHRA    AND    PENIS. 


gained  by  a  study  of  the  accompanying  illustration,  varies  with  the  age 
of  the  individual  and  also  with  the  condition  of  the  bladder  and  rectum. 
A  full  rectum  pushes  the  prostate  upwards;  a  full  bladder  pushes  it 


Fig.   1 20. 

downwards  and  thereby  lessens  the  circumference  of  the  urethral  curve. 

(c)    LENGTH. 

The  length  of  the  male  urethra  varies  from  18  to  20  cm.  (7  to  8  inches) 
about  13  (5|-  inches)  of  which  are  taken  up  by  the  anterior  portion, 
(Fig.  121  a  d),  2  (-£-  of  an  inch)  by  the  membranous,  (b)  and  2  to  3  (f  to 
1  inch)  by  the  prostatic  part. 

(d)    CALIBER. 
The  caliber  of  the  urethra  is  not  uniform,,  varying  in  its  different  parts. 
The  wide-spread  error  that  the  urethra  is  an  open  tube  must  be  corrected, 


THE    MALE    URETHRA. 


87 


for  in  reality  it  is  a  long,  closed  canal,  the  walls  of  which  lie  in  appo- 
sition except  when  an  instrument  is  introduced,  or  when  urine  or  semen 
passes  through  it.  The  urethral  mucous  membrane  is  arranged  in  fla- 
belliform  folds  placed  one  upon  the  other,  and  it  is  for  this  reason  that 
the  two  walls  come  in  contact. 

The  narrowest  part  of  the  urethra  is  at  the  external  orifice,  behind  which 
there  is  an  expansion,  the  fossa  navicularis  (Fig.  121a);  behind  this  the 
canal  remains  of  equal  caliber  down  to  the  bulb,  where  the  greatest  ex- 
pansion takes  place  in  the  form  of  a  sac  or  pouch  (Fig.  121  d).  A  con- 
siderable degree  of  narrowing  occurs  at  the  point  where  the  bulb  passes 
into  the  membranous  portion,  and  then  a  further  dilatation  is  found  in 
the  middle  of  the  prostatic  part.  A  slight  narrowing  is  present  at  the 
internal  orifice.  These  relations  are  well  represented  in  Figure  12  [, 
taken  from  the  work  of  Sir  Everard  Home.  It  will  be  seen  thai  the 
expansion  and  contraction  occur  on  the  posterior  waii,  or  floor,  of  ihc 
urethra,  the  anterior  wall,  or  roof,  Deing  practically  uniform  throughout 
its  length. 


The  absolute  caliber  of  the  urethra  is  determined  by  the  size  of  in  - 
struments  which  it  will  admit.  The  instruments  are  measured  by 
means  of  a  draw-plate,  the  apertures  of  which  are  supplied  with  num- 
bers representing  their  circumference  in  millimeters.  This  method  of 
measuring  is  of  French  origin,  having  been  devised  by  Charriere;  there- 
fore we  speak  of  such  and  such  a  number  of  the  Charriere  scale,  No.  20, 
for  instance,  being  an  instrument  which  just  passes  through  the  open- 
ing numbered  20.  [In  America  and  England  it  is  customary  to  refer  to 
this  scale  as  the  French  scale  instead  of  calling  it  by  the  name  of  its 
originator.] 

The  English  scale  is  also  often  used.     Its  relation  to  the  French  scale 


8  DISEASES    OF    THE    URETHRA    AND    PENIS. 

is  about  that  of  i :  3,  so  that  No.  6  English  corresponds  approximately 
to  No.  18  French. 

It  is  incorrect  to  measure  the  urethra  with  an  Urethrometer,  after 
the  method  of  Otis,  because  this  instrument  stretches  the  urethra  and 
thus  makes  it  impossible  to  tell  how  much  of  the  dilatability  is  natural 
and  how  much  artificial.  The  urethrometer  is  a  staff-like  instrument 
one  end  of  which  opens  into  a  bulb  by  means  of  a  thumb  screw.  [A 
dial  at  the  other  end  registers  the  degree  of  expansion  in  millimetres]. 

Otis's  declaration  that  the  circumference  of  the  penis  and  the  caliber 
of  the  urethra  bear  a  definite  relation  to  one  another  is  also  erroneous, 
for  oftentimes  a  man  with  a  small  penis  will  have  a  capacious  urethra 
and  one  having  a  large  penis  will  have  a  narrow  urethra. 

(e)    THE    RELATIONS    OF    THE    MALE    URETHRA    TO    THE    TRUE    PELVIS. 

It  is  of  great  practical  importance  to  understand  that  the  male 
urethra  lies  partly  without  and  partly  within  the  true  pelvis.  The 
pelvic  floor  is  closed  by  a  part  of  the  pelvic  fascia,  the  lamina  media, 
or  the  fascia  perinei  propria,  also  called  the  uro-genital  diaphragm 
[triangular  ligament].  This  fascia  is  triangular  in  form,  the 
apex  of  the  triangle  being  at  the  symphysis  pubis,  while  its  base  is 
at  the  sacrum.  The  inner  surface  of  this  diaphragm  extends  upwards 
and  backwards  and  is  in  relation  with  the  prostate  and  bladder;  its 
outer  surface  is  in  relation  with  the  corpora  cavernosa  and  a  fissure 
between  the  bulbo  cavernosus  and  ischio  cavernosus  muscles.  It  forms 
a  partition  between  the  organs  within  and  without  the  pelvis. 
The  urethra  passes  through  this  diaphragm  just  behind  the  bulb,  at  the 
beginning  of  the  membranous  portion,  so  that  the  anterior  urethra  lies 
without  the  pelvis,  while  the  posterior  urethra  is  a  pelvic  organ. 

URETHRITIS. 

Every  inflammation  of  the  urethra,  is  called  urethritis.  It  is  due 
either  to  trauma  or  to  infection. 

Tears  of  the  urethra,  wounds,  caustic  injections  such  as  corrosive 
sublimate  or  carbolic  acid,  foreign  bodies  such  as  calculi  or  the  reten- 
tion catheter,  all  produce  catarrhal  conditions  in  the  urethra  which  are 
manifested  as  purulent  discharges,  or  when  of  lesser  severity,  by  the 
presence  of  filaments  in  the  urine. 

It  is  not  necessary  to  assume  that,  owing  to  accidental  conditions  of 
the  urethra — as  irritation  for  example — the  microorganisms  normally 


URETHRITIS.  89 

present  there  require  power  to  produce  inflammation,  because  similar 
processes  in  which  no  microorganisms  whatever  are  present  also  occur 
(urethritis  aseptica). 

Thus,  if  a  5  per  cent  solution  of  carbolic  acid  be  injected  into  the 
urethra,  an  intense  suppurative  inflammation  results,  although  neither 
microscopic  examination  nor  culture  methods  reveal  bacteria  in  the  dis- 
charge. It  is  true  that  the  period  during  which  they  are  absent  is  of 
short  duration,  for  wherever  suppuration  exists  bacteria  soon  appear. 
In  these  cases,  however,  they  should  not  be  considered  the  primary 
causative  agents,  but  rather  nosoparasites  in  the  true  sense  of  the  word. 

I  cannot  acknowledge  the  existence  of  urethritis  resulting  from 
excessive  indulgence  in  alcohol,  nor  have  I  observed  it  in  association 
with  gout  and  rheumatism.  The  occurrence  of  herpetic  urethritis, 
however,  is  not  to  be  questioned,  for  herpes  may  attack  the  mucous 
membrane  of  the  urethra  just  as  it  attacks  any  other  mucous  mem- 
brane, and  so  give  rise  to  circumscribed  inflammation  resembling  that 
produced  by  any  other  source  of  irritation  which  we  have  mentioned. 

All  these  forms  are  characterized  by  their  benignity  and  ready 
curability.  As  soon  as  the  cause  is  overcome — the  irritation  discon- 
tinued or  the  foreign  body  removed — a  few  injections  of  a  weak 
astringent  solution,  such  as  zinc  sulphate  i :  ioo,  serve  to  check  the 
discharge.  These  forms  of  urethritis  are  so  rare  that  they  are  of  little 
importance  in  comparison  with  bacterial  urethritis. 

Concerning  the  bacterial  forms  all  except  the  gonorrhceal  may  be 
dismissed  with  slight  mention.  A  few  cases  of  urethritis  due  to  micro- 
organisms other  than  the  gonococcus  have  been  reported,  and  I  myself 
have  seen  some  cases  of  undoubted  authenticity.  The  potentiality  of 
producing  an  urethritis  has  been  imputed  to  numerous  microorgan- 
isms, but  the  observations  are  so  few  and  the  bacteriologic  relations  as 
yet  so  obscure  that  we  must  restrict  ourselves  here  to  the  mere  mention 
of  the  occurrence  of  such  cases. 

I  do  wish  to  state,  however,  that  the  prognosis  in  these  forms  of  bac- 
terial urethritis,  which  are  called  simple  urethritis,  is  not  so  favorable 
as  has  generally  been  supposed.  There  are  cases  of  chronic  non-gon- 
orrhceal  urethritis  which  in  spite  of  treatment  lead  to  complications — as 
for  example,  prostatitis — identical  with  those  produced  by  true  chronic 
gonorrhoea. 

The  so-called  urethrorrhcea  ex  libidine,  and  bacteriorrhcea  are  quite 
harmless  affections.     In  the  first,  as  the  result  of  frequent    sexual 


QO  DISEASES    OF    THE    URETHRA    AND    PENIS. 

excitement,  a  viscid  drop  of  mucus,  or  perhaps  only  a  slight  moisture, 
appears  at  the  meatus.  This  is  merely  the  normal  secretion  of  the 
urethral  glands,  which  has  exuded  as  a  result  of  the  increased  volume  of 
the  penis  produced  by  erection. 

Bacteriorrhcea  manifests  itself  as  a  thin,  grayish,  mucoid  secretion  at 
the  meatus,  being  most  profuse  in  the  morning,  although  occurring  in 
lesser  degree  during  the  day.  It  retains  its  original  characteristics  as 
long  as  it  remains  untreated.  If  this  discharge  be  examined  under  the 
microscope  it  is  seen  that  leucocytes  and  epithelial  cells  are  not 
predominant,  as  they  are  in  urethritis,  but  that  a  large  number  of 
bacteria  of  different  forms  are  present,  bacilli,  cocci,  diplococci,  and 
organisms  arranged  in  chains  and  clusters  all  being  in  the  field.  Cell- 
ular elements  are  almost  entirely  wanting,  although  here  and  there  a 
few  round  or  epithelial  cells  may  be  discovered.  I  have  never  observed 
any  injurious  effects  from  this  discharge;  it  does  not  increase,  causes 
no  annoyance,  and  I  have  never  known  infection  to  be  conveyed  by  it. 
This  bacteriorrhcea  often  remains  as  a  sequel  of  gonorrhoea,  especially 
after  an  attack  of  long  duration. 

Gonorrhoeal  Urethritis,  or  clap,  as  it  occurs  in  man  (the  disease 
in  woman  not  being  pertinent  to  our  subject)  is  caused  by  the 
lodgment  of  a  specific  organism,  the  gonococcus,  in  the  urethra. 
It  is  not  always  enough  for  the  gonococcus  to  gain  access  to  the  urethra, 
since  there  are  undoubted  instances  in  which  two  men  have  been 
exposed  to  the  same  infection  and  only  one  of  them  developed  disease, 
the  other  remaining  perfectly  well.  Persons  of  the  latter  class  are  only 
slightly  susceptible  to  gonorrhoeal  virus.  Unfortunately,  however, 
they  constitute  the  exception,  exposure  being  almost  synonymous  with 
infection. 

The  gonococcus  of  Neisser  is  a  diplococcus  characterized  by  the 
following  properties.  In  form  it  is  a  diplococcus  somewhat  resembling  a 
coffee-bean,  its  flat  surfaces  being  divided  by  a  fine  cleft  and  its  convex 
surfaces  lying  outward  (Fig.  122).  In  a  are  seen  pus-corpuscles  con- 
taining gonococci,  in  b  gonococci  on  epithelial  cells,  in  c  gonococci 
between  the  cells.  During  propagation  the  voung  bacteria  are  arranged 
with  their  long  axis  perpendicular  to  the  old  ones;  that  is,  they  occur 
in  clusters  instead  of  chains. 

They  are  intracellular,  penetrating  both  epithelium  and  leucocytes, 
especially  the  latter,  and  taking  up  their  abode  close  to  the  nuclei.  If 
the  cellular  membrane  bursts  they  are  also  found  between  the  cells. 


URETHRITIS.  9 1 

Diplococci  can  positively  be  pronounced  gonococci  only  when  they  are 
observed  within  as  well  as  between  the  cells. 

Gonococci  stain  with  the  basic  aniline  dyes;  they  differ  from  other 
diplococci  occurring  in  the  urethra  in  that  they  are  decolorized  by 
Gram's  stain  (iodine,  potassium  iodide  and  absolute  alcohol). 

[To  examine  urethral  discharge  for  gonococci  make  spreads  on 
perfectly  clean  cover-glasses,  which  may  be  done  either  by  smearing 
a  small  quantity  of  the  secretion  over  them  with  a  platinum  needle, 
or  by  touching  the  meatus  with  one  cover-glass,  placing  a  second  one 
upon  it,  and  then  drawing  the  two  apart  so  as  to  distribute  the 
secretion  thinly  and  evenly  over  both.     Care  must  be  taken  not  to 


Fig.  122. — Gonococci.     a,  Masses  inclosed  in  pus-cells      b,  The  same 
in  epithelial  cells,     c,  Gonococci  floating  free  in  the  secretion. 


get  too  much  secretion  lest  the  spreads  be  made  too  thick.  The 
spreads  are  allowed  to  dry  and  are  then  passed  through  the  flame  of  a 
Bunsen  burner  or  spirit  lamp  three  times. 

A  number  of  different  stains  are  satisfactory.  A  concentrated 
aqueous  or  alcoholic  solution  of  methylene  blue  stains  the  protoplasm 
and  nuclei  of  the  pus  cells,  as  well  as  the  gonococci,  a  deep  blue. 
This  is  a  very  simple  method  of  staining. 

A  saturated  alcoholic  solution  of  methylene  blue  may  be  used  from 
five  to  fifteen  minutes,  the  specimens  washed  in  water  and  then 
stained  for  the  same  length  of  time  in  a  saturated  alcoholic  solution 
of  eosin,  after  which  they  are  again  washed  in  water  and  then  mounted. 
The  gonococci  and  the  nuclei  of  the  pus-corpuscles  are  stained  blue 
and  the  protoplasm  of  the  pus-cells  pink. 

In  either  of  these  two  methods  Gram's  solution  should  be  applied 
to  one  specimen  to  determine  if  the  diplococci  decolorize. 


92  DISEASES    OF    THE    URETHRA    AND    PENIS. 

Mallory  and  Wright  recommend  the  following  method: 

i.  Stain  in  a  solution  of  aniline  gentian-violet  for  thirty  seconds. 

2.  Wash  in  water. 

3.  Place  in  Gram's  solution  for  thirty  seconds. 

4.  Wash  in  water. 

5.  Immerse  in  95  per  cent  alcohol  until  the  color  ceases  to  come  out. 

6.  Wash  in  water. 

7.  Stain  in  a  saturated  aqueous  solution  of  Bismarck  brown  for 
thirty  seconds. 

8.  Wash  in  water  and  mount. 

The  gonococci  are  stained  brown,  other  pyogenic  cocci  blue-black. 

Dr.  W.  F.  Whitney  uses  a  1  per  cent  aqueous  solution  of  pyronin 
instead  of  Bismarck  brown.     This  stains  the  gonococci  red.] 

The  gonococci  also  require  a  special  culture  medium  for  their  growth 
which  is  not  the  case  with  other  urethral  diplococci.  They  grow  on 
human  blood-serum,  thriving  best  upon  a  mixture  of  blood-serum,  or 
serous  fluid  such  as  hydrocele-fluid,  and  agar.  They  grow  excellently 
at  a  temperature  of  300  C.  Above  38°  C.  they  lose  their  power  of 
development. 

That  the  gonococcus  is  the  specific  cause  of  gonorrhoea  is  at  present 
not  doubted.  The  urethra  has  been  inoculated  with  this  organism 
after  it  had  passed  through  several  successive  cultures  and  a  typical 
gonorrhoea  has  resulted  in  every  instance. 

The  gonococcus  retains  its  virulence  outside  the  body,  a  property 
which  explains  the  occurrence  of  infection  by  means  of  contaminated 
linen,  dirty  instruments,  chamber-vessels,  etc.  This  form  of  infection 
occurs  most  frequently  in  little  girls,  although  I  have  seen  a  case  in  a 
boy  two  years  old. 

We  divide  gonorrhoea  according  to  its  clinical  manifestations  into 
an  acute  and  chronic  form,  and  also  into  an  anterior  and  posterior 
form,  which  may  be  either  acute  or  chronic. 

PATHOLOGICAL    ANATOMY. 

The  gonococci,  after  gaining  access  to  the  urethra,  penetrate  the 
mucous  membrane  and  begin  to  multiply  very  rapidly.  They  are 
present  not  only  in  the  discharge,  which  consists  mostly  of  pus-cells 
cast  off  from  the  surface  of  the  urethra,  but  also  in  the  subepithe- 
lial tissue,  the  crypts  of  Morgagni,  and  the  glands  of  Littre.  Their 
enormous  increase  in  number  causes  an  inflammation,  as  the  result  of 


URETHRITIS.  93 

which  the  urethral  mucous  membrane  becomes  swollen,  cedematous, 
and  injected. 

Leucocytic  infiltration  occurs,  the  white  cells  collecting  between  the 
epithelium  and  destroying  it.  They  invade  the  outlets  of  the  glandular 
ducts,  penetrating  as  deep  as  the  subepithelial  connective  tissue, 
between  the  cells  of  which  they  may  be  seen  if  a  section  of  tissue  is 
examined  under  the  microscope.  They  likewise  attack  the  glandular 
cells  and  periglandular  tissues,  forcing  their  way  even  into  the  crypts 
of  Morgagni  and  the  glands  of  Littre;  in  fact,  this  infiltration  of 
polymorphonuclear  leucocytes  is  universal. 

The  process  involves  the  surface  of  the  urethra  as  well  as  its  deeper 
layer,  and  tends  constantly  to  extend  backwards.  As  long  as  it  does 
not  pass  beyond  the  bulb  we  designate  it  as  anterior  gonorrhoea; 
when  it  exceeds  this  limit  it  is  known  as  posterior  gonorrhoea. 

Fortunately  the  latter  occurrence  is  not  very  frequent  during  the 
acute  stage  of  the  disease,  but  it  happens  almost  invariably  in  the 
chronic  stage,  as  we  shall  see  later. 

The  transition  from  anterior  to  posterior  urethritis  may  take  place  at 
any  time,  and  I  have  seen  it  occur  as  early  as  the  second  day ;  the  time 
of  predilection,  however,  is  during  the  second  or  third  week.  The 
gonorrhceal  inflammation  travels  backward  slowly,  and  in  a  certain 
number  of  cases,  which  generally  subside  in  from  four  to  six  weeks,  is 
arrested  at  the  bulb.  If  it  goes  beyond  this  point  into  the  posterior 
urethra,  a  further  involvement  of  both  the  deep  and  superficial  strata  is 
the  usual  result.  When  the  deep  layers  are  affected  catarrhal  inflamma- 
tion of  the  prostatic  ducts,  the  orifices  of  the  seminal  vesicles  and  their 
surrounding  tissue,  and  finally  of  the  prostate  itself,  the  seminal  vesicles, 
and  even  the  epididymis  occurs.  If  the  extension  takes  place  super- 
ficially the  bladder  becomes  affected  and  a  gonorrhceal  cystitis  is 
produced.  In  many  cases  the  deep  and  superficial  layers  suffer 
simultaneously. 

This  acute  process,  which  affects  both  the  anterior  and  posterior 
urethra,  may  terminate  in  either  one  of  two  ways.  If,  under  appro- 
priate treatment,  the  number  of  gonococci  diminish  and  their  virul- 
ence becomes  attenuated,  then  the  leucocytic  infiltration  decreases. 
The  small  embryonal  cells  disintegrate  and  are  absorbed  and  normal 
epithelium  forms  on  the  previously  diseased  areas,  so  that  a  complete 
restitutio  ad  integrum  is  brought  about. 

Unfortunately  this  is  not  the  invariable  termination,  for  although 


94  DISEASES    OF    THE    URETHRA    AND    PENIS. 

the  inflammation  and  small-celled  infiltration  decrease,  they  do  not 
entirely  disappear,  and  what  is  known  as  chronic  urethritis 
results.  In  this  condition  gonococci  may  be  present  or  absent.  Thus 
it  is  seen  that  the  continuation  of  a  chronic  urethral  catarrh  is  not 
dependent  upon  the  presence  of  gonococci.  Indeed,  the  inflammatory 
infiltrate  may  persist  for  years  or  even  decades  after  the  primary  cause 
of  the  affection  has  been  removed. 

This  chronic  process  is  essentially  a  small-celled  infiltration,  which 
may  affect  any  part  of  the  urethra  from  the  meatus  to  the  neck  of  the 
bladder  and  involve  both  its  superficial  and  deep  structures,  but  which 
seems  to  have  a  special  affinity  for  the  glandular  portions,  such  as 
Littre's  glands  and  Morgagni's  lacunae,  together  -with  their  adjacent 
tissues;  moreover,  it  may  penetrate  to  the  deeper  layers  of  sub- 
epithelial and  connective  tissues,  and  even  force  its  way  into  the 
corpora  cavernosa. 

Some-  of  this  infiltrate  undergoes  absorption  and  some  of  it  becomes 
converted  into  connective  tissue,  the  latter  forming  a  callus  or  scar. 
Obliteration  of  blood-vessels  follows,  as  the  result  of  which  the  cylin- 
drical epithelium  is  changed  into  squamous  epithelium,  which  becomes 
partly  cornified.  These  infiltrations  do  not  effect  the  whole  length  of 
the  urethra,  but  are  localized.  More  and  more  plastic  material  is 
deposited,  so  that  scar  is  superimposed  upon  scar  until  finally,  in 
course  of  time,  a  perceptible  degree  of  thickening  results,  which  is 
known  as  a  callus,  and  which  constitutes  a  stricture  of  the 
urethra. 

Chronic  urethritis,  however,  corresponds  rather  to  that  period  of  time 
during  which  the  infiltrative  process  does  not  increase  to  such  an  extent 
as  to  produce  perceptible  narrowing  of  the  urethra ;  in  fact,  a  large  num- 
ber of  these  cases  never  advance  to  stricture  formation  because  the  infil- 
trate is  confined  to  a  few  limited  areas,  mostly  glands  and  their  neighbor- 
ing tissues.  Thus  it  continues  as  a  chronic,  discharging  urethritis,  the 
secretion  being  due  to  disintegration  of  the  newly  formed  infiltrate; 
the  leucocytes  likewise  accumulate  again,  and  so  the  process  con- 
tinues, often  for  an  indefinite  period. 

SYMPTOMATOLOGY. 

(a).  Acute  gonorrhoea.  The  incubation  period  of  gonorrhoea, 
which  pursues  its  course  without  any  symptoms,  lasts  from  one  to  six 
days.     Generally  the  signs  of  infection  begin  to  manifest  themselves  by 


URETHRITIS.  95 

the  third  day  after  exposure.  A  slight  burning  sensation  is  experienced 
in  the  urethra,  and  an  itching  is  felt  during  urination,  while  between 
the  acts  of  micturition  there  is  a  sense  of  moisture  at  the  meatus.  Very 
soon  the  secretion  develops  in  abundance.  At  first  it  is  mucoid,  then 
muco-purulent  and  finally  purulent;  occasionally  it  is  stained  with  blood 
(Russian  clap).  In  this  discharge  gonococci  are  always  found  in  the 
typical  form  above  described. 

The  inflammatory  phenomena  increase,  the  pain  becomes  more 
severe,  urination  frequently  causing  such  exquisite  pain  that  the 
patient  refrains  from  passing  his  water.  The  area  around  the  meatus 
is  red  and  swollen,  the  lips  of  the  meatus  cedematous. 

The  inflammation  produces  erections,  which  are  frightfully  painful, 
for  the  reason  that  the  swollen  mucous  membrane  cannot  expand  to 
accommodate  itself  to  the  increased  volume  of  the  penis. 

This  acute  stage  soon  passes  into  the  subacute  stage,  the  time  required 
for  its  transition  depending  upon  the  appropriateness  of  treatment. 
The  inflammatory  phenomena  diminish  from  day  today;  micturition 
becomes  less  painful  until  finally  only  a  slight  smarting  is  felt ;  the  dis- 
charge diminishes  and  loses  its  greenish  yellow  color,  becoming  again 
a  grayish  yellow,  muco-purulent  secretion. 

This  stage  may  supervene  at  the  expiration  of  a  week  or  ten  days, 
although  there  are  many  cases  in  which  the  inflammatory  stage  lasts  until 
into  the  third  week.  Then  the  symptoms  become  milder  and  milder, 
the  discharge  dries  up  and  only  a  small  drop  of  mucus-like  secretion  is 
seen  at  the  meatus  after  long  intervals  between  micturition.  All  pain 
and  discomfort  have  now  entirely  disappeared.  If  the  urine  be  voided  in 
two  portions,  the  second  will  be  found  entirely  clear,  while  the  first  will 
contain  flocculi.  Finally  these  will  disappear,  and  the  disease  can  then 
be  considered  cured. 

In  many  cases  of  acute  gonorrhoea  the  inflammatory  stage  just 
described  is  entirely  wanting.  They  begin  with  slight  purulent  or  mucoid 
secretion  which  retains  its  original  character  throughout  the  course  of  the 
disease.  Signs  of  inflammation ,  such  as  swelling  of  the  meatus  and  pain- 
ful micturition,-  do  not  occur.  These  non-inflammatory  claps  are  seen 
especially  in  patients  who  formerly  have  passed  through  an  attack  of 
gonorrhoea.  It  even  happens  that  the  infection  produces  so  little  dis- 
turbance as  to  pass  unnoticed  by  the  patient  until  he  discovers  it  acci- 
dentally or  an  exacerbation  attracts  his  attention  to  it.  In  this  way  are 
explained  the  cases  in  wrhich  gonorrhceal  shreds,  or  even  discharge  are 


96  DISEASES    OF    THE    URETHRA    AND    PENTS. 

found,  notwithstanding  the  fact  that  the  patients  assert  they  never  had 
gonorrhoea. 

In  most  instances,  though  not  always,  the  disease  pursues  the  favor- 
able course  above  described,  from  four  to  six  weeks  usually  being 
required  for  its  subsidence.  In  all  these  cases,  which  may  best  be  called 
those  free  from  complications,  the  inflammatory  process  does  not  extend 
beyond  the  bulb  of  the  urethra. 

If  it  pass  beyond  this  point  during  the  acute  stage,  an  acute  posterior 
gonorrhoea  results,  and  the  entire  symptom-complex  becomes  immedi- 
ately changed.  While  acute  anterior  gonorrhoea  produces  scarcely  any 
general  disturbance,  patients  having  acute  posterior  urethritis  are  often 
feverish  and  present  the  appearance  of  being  afflicted  with  a  serious 
malady.  Although  the  purulent  discharge  becomes  less,  or  disappears 
entirely,  three  symptoms  develop  which  make  the  clinical  picture  a 
typical  one:  1.  Severe  strangury  occurs,  the  patients  being 
forced  to  urinate  frequently  both  day  and  night,  sometimes  as 
often  as  every  fifteen  minutes;  2.  Micturition  is  painful,  the 
pain  most  commonly  supervening  at  the  end  of  micturition  and 
lasting  for  some  time  thereafter;  3.  The  second  portion  of 
the  urine  is  cloudy,  the  turbidity  being  due  to  pus.  Not  un- 
commonly terminal  haemorrhage  occurs,  the  last  drops  of  urine 
being  tinged  with  blood.  In  exceptional  cases  the  entire 
quantity  of  urine  voided  is  blood-stained. 

The  turbidity  of  the  second  portion  of  urine  is  explained  as  follows : — 
We  know  that  the  anterior  urethra  is  shut  off  from  the  posterior  by  con- 
traction of  the  musculus  compressor  partis  membranosce  urethra,  also 
termed  the  sphincter  vesica,  extemus,  so  that  fluid  in  the  anterior  urethra 
(be  it  an  accumulation  of  pus  or  an  injection),  flows  toward  the  external 
orifice.  If  a  considerable  quantity  of  pus  accumulate  in  the  posterior 
urethra,  or  if  fluid  be  injected  into  it,  the  resistance  of  the  internal  vesical 
sphincter  is  overcome  and  the  fluid  flows  into  the  bladder.  The  pus  is 
dissolved  by  the  urine  and  renders  it  turbid.  Thus  it  is  that  in  every 
freely  suppurating  posterior  urethritis  the  second  portion  of  the  urine  is 
cloudy.  The  first  portion  is  even  more  turbid  than  the  second,  because 
it  contains  not  only  pus  derived  from  the  bladder,  but  also  that  which  it 
washes  out  from  the  urethra. 

This  property  serves  to  distinguish  it  from  the  urine  of  cystitis,  the 
second  portion  of  wThich  is  more  turbid  than  the  first,  because  no  secre- 
tion is  added  to  it  in  its  passage  through  the  urethra;  morover,  the 


URETHRITIS.  97 

portion  first  voided  represents  the  upper  part  of  the  urine  contained 
in  the  bladder,  whereas  the  second  portion  consists  of  the  purulent 
sediment. 

In  such  cases  gonorrhceal  cystitis  usually  develops.  Posterior 
urethritis,  unless  promptly  and  energetically  treated,  is  the  forerunner 
of  cystitis.  A  series  of  complications  is  threatened.  Unfortunately  the 
gonorrhceal  process  often  extends  to  the  prostatic  ducts  and  produces  a 
prostatitis.  In  like  manner  inflammation  of  the  vasa  deferentia, 
epididymis  and  seminal  vesicles  may  develop. 

On  the  other  hand  acute  posterior  urethritis,  especially  under  rational 
treatment,  may  pursue  a  favorable  course;  all  symptoms  and  signs — 
tenesmus,  pain,  cloudy  urine— disappear  and  the  patient  escapes  com- 
plications. Most  frequently,  however,  the  inflammation  becomes 
chronic,  and  when  it  does  gonorrhceal  prostatitis  is  almost  always  the 
result. 

(&).  Chronic  gonorrhoea.  If  the  disease  has  not  subsided  by  the 
end  the  the  sixth  week  we  then  speak  of  it  as  chronic  gonorrhoea,  a,  con- 
dition in  which  the  distinction  between  anterior  and  posterior  gonorrhoea 
is  less  pronounced ;  and  is  also  less  significant,  because  nearly  all  cases 
of  chronic  gonorrhoea  involve  both  the  anterior  and  posterior  urethra. 

Ordinary  chronic  gonorrhoea  cannot  be  distinguished  from  the  last 
stage  of  the  acute  form.  Urethral  discharge  is  present  in  a  certain 
number  of  cases,  and  may  either  be  profuse  enough  to  be  detected  at  the 
meatus  or  so  slight  as  to  be  manifested  only  by  the  presence  of  filaments 
in  the  urine.  If  the  patient  urinates  in  two  glasses  the  filaments  will  be 
present  chiefly  in  the  first  glass,  although  some  may  be  observed  in  the 
second.  The  more  abundant  the  secretion,  the  thicker  the  flocculi,  for 
heavy  pus- flakes  sink  quickly  to  the  bottom  of  the  glass  whereas  thinner 
mucous  shreds  float  in  the  fluid  for  some  time. 

Subjective  symptoms  may  be  entirely  absent;  neither  painful  urina- 
tion nor  strangury  are  necessarily  present  even  when  the  disease  affects 
the  neck  of  the  bladder. 

With  the  exception  of  filaments  the  urine  becomes  clear  as  soon  as  the 
discharge  becomes  slight.  As  the  purulent  secretion  is  confined  to  the 
posterior  urethra  and  first  mingles  with  the  urine  when  the  latter  is 
voided,  it  cannot  produce  turbidity.  When  the  urine  is  allowed  to 
stand  for  a  long  time  then,  of  course,  the  filaments  are  dissolved  and 
cause  a  cloudiness.  If  the  secretion  of  pus  be  very  abundant  then  the 
second  portion  of  the  freshly  voided  urine  will  also  be  turbid.  There- 
7 


98 


DISEASES    OF    THE    URETHRA    AND    PENIS. 


fore,  although  a  freshly  voided  clear  urine  does  not  show  that  posterior 

urethritis  is  not  present,  a  freshly  voided  turbid  urine  assures  us  of  its 

existence. 

In  addition  to  the  not  very  important  classification  of  chronic  gonor- 
rhoea into  an  anterior  and  posterior  form,  another  division 
must  be  made  from  the  standpoint  of  treatment,  namely, 
that  of  a  superficial  and  deep  catarrh. 

We  have  considered  the  morbid  anatomy  of  chronic 
gonorrhoea  and  seen  that  it  is  a  small-celled  infiltration 
which  partly  undergoes  resorption  and  partly  changes  into 
scar-tissue,  whereby  relapses  frequently  occur.  If  this 
process  is  confined  to  the  surface  of  the  urethra,  to  the 
glands  and  their  surroundings,  only  a  superficial  catarrh  is 
the  result;  if  it  penetrates  into  the  deeper  parts,  into  the 
submucous  connective  tissue  or  even  into  the  corpora 
cavernosa,  and  displays  a  tendency  to  develop  scar-tissue 
from  the  embryonal  cells  instead  of  undergoing  resorption, 
a  deep  seated  catarrh  is  produced,  and  we  have  to  do 
with  infiltrative  processes. 

This  latter  condition  is  characterized  clinically  by  per- 
ceptible narrowing  of  the  caliber  of  the  urethra,  while  in 
the  superficial  form  no  such  narrowing  is  present.  This 
encroachment  upon  the  lumen  of  the  uerthra  is  not  always 
so  great  that  it  can  be  detected  with  an  ordinary  sound, 
especially  since  the  external  meatus  is  the  narrowest  part 
of  the  urethra.  If  we  assume  that  the  meatus  just  allows 
the  passage  of  an  instrument  whose  caliber  is  22  F.,  while 
the  bulb,  which  normally  may  be  dilated  to  40  mm.  has 
undergone  a  diminution  of  10  mm.  as  the  result  of  infiltra- 
tion, it  is  evident  that  the  narrowing  cannot  be  detected  by 
a  22  sound.  The  bougie  a  boule,  or  the  Otis  urethrometer, 
will  often  reveal  its  existence,  but  the  urethroscope  is  more 
certain  than  either  of  these  instruments. 

The  urethrometer  (Fig.  123)  is  an  instrument  having  at 

its  tip  a    bull  composed  of  separate  blades,  which  may  be  opened  to 

40  F.  by  means  of  a  thumb-screw.     A  dial  at  the  other  end  registers 

the  degree  of  expansion  in  millimeters. 

The  surest  methed  of  diagnosis  is  urethroscopy  (g.  v.),  which  gives 

a  typical  picture  of  the  infiltrate.     Diminution  or  absence  of  the  plica- 


Fig.  123 

Otis's 

urethrometer. 


URETHRITIS.  99 

tions,  disappearance  of  the  striations,  irregular  blemishes  of  the  mucosa, 
abnormal  paleness,  loss  of  luster,  and  rigidity  are  all  revealed. 

Of  greater  importance  is  the  question  of  the  infectiousness  of 
gonorrhoea.  It  is  self-evident  that  as  long  as  gonococci  are  present 
in  the  discharge  so  long  is  the  discharge  infectious.  The  difficulty  lies 
in  the  fact  that  gonococci  may  be  present  and  yet  not  be  found. 
Daily  experience  teaches  that  they  are  not  constantly  demonstrable, 
being  present  at  one  time  and  absent  at  another.  The  reason  for  this 
is  that  they  remain  latent  in  the  deeper  portion  of  the  urethra  and  only 
come  to  the  surface  at  intervals,  or  when  perchance  an  exacerbation 
of  inflammation  increases  the  discharge.  They  burrow  in  the  glands, 
in  the  submucous  infiltrate,  and  especially  in  the  prostate,  retaining 
their  vitality  for  months  and  even  years. 

In  view  of  these  circumstances  when  shall  we  permit  a  man  who  has 
had  gonorrhoea  to  marry?  The  dictum,  "not  before  the  last  remnant 
of  discharge  has  disappeared"  cannot  be  accepted  in  practice.  We 
know  that  a  large  number  of  men  who  have  had  gonorrhoea  are  never 
entirely  free  from  the  relics  of  their  disease,  as  their  urine  contains  fila- 
ments. If  we  were  to  forbid  all  such  to  marry  they  certainly  would  not 
obey  us;  and  if  they  did  the  number  of  unhappy  mortals  in  the  world 
would  be  greatly  increased,  the  list  of  neurasthenics  and  hypochondriacs 
would  become  larger,  and  mankind  would  even  be  in  danger  of  extinc- 
tion. We  well  know  that  many  such  men  marry  and  never  infect  their 
wives,  although  it  is  true,  too,  that  infection  has  been  conveyed  by  men  in 
whom  the  most  careful  examination  failed  to  show  gonococci.  In  my 
experience,  however,  the  latter  occurrence  is  rare.  Concerning  the 
question  of  marriage  I  have  adopted  the  following  rule: — 

If  the  patient  has  any  abnormal  secretion,  be  it  shown  by  urethral  dis- 
charge or  bv  filaments  in  the  urine,  it  must  be  repeatedly  examined  at 
long  intervals  for  gonococci.  If  filaments  are  present  the  urine  is  centri- 
fuged  and  the  precipitate  stained.  If  all  examinations  are  negative  the 
urethra  is  irritated  by  natural  or  artificial  means  (cohabitation,  free  use 
of  strong  alcoholic  beverages,  irritant  injections  like  nitrate  of  silver). 
If  the  increased  secretion  thus  produced  shows  no  gonococci  then 
marriage  may  be  permitted.  Possibly  this  course  may  result  in  an 
occasional  mistake,  but  in  the  present  state  of  our  knowledge  we 
possess  no  other  criteria  of  infectiousness  and  so  are  obliged  to  choose 
the  lesser  of  two  evils. 

The  composition  of  the  secretion  is  of  no  special  consequence,  it 


IOO  DISEASES    OF    THE    URETHRA    AND    PENIS. 

being  immaterial  whether  it  consists  chiefly  of  pus-cells  with  a  little 
epithelium,  or  whether  it  be  made  up  entirely  of  pus-cells.  Epithe- 
lium alone  shows  that  the  process  is  distinctively  desquamative  and 
pus-cells  denote  the  existence  of  catarrh.  The  principal  question  to 
be  determined  is  whether  gonococci  are  present. 

Every  case  of  gonorrhoea,  from  its  very  inception  to  its  termination, 
is  subject  to  a  series  of  complications;  this  is  true  even  in  the  period 
when  gonococci  no  longer  are  present  and  the  condition  may  be 
rightly  termed  urethritis.  We  will  now  briefly  discuss  the  principal 
complications. 

LYMPHANGITIS  AND  LYMPHADENITIS. 

Both  occur  almost  exclusively  in  acute  gonorrhoea.  The  gonorrhceal 
process  extends  into  the  lymphatic  vessels  and  glands.  Occasionally, 
though  not  often,  it  happens  that  the  lymphatics  become  so  acutely 
inflamed  as  a  result  of  previous  swelling  of  the  prepuce  and  penis  that 
they  rupture  and  from  periurethral  abscesses.  Much  more  frequently 
they  become  chronically  swollen  and  indurated,  so  that  they  are  palpable, 
especially  on  the  dorsum  of  the  penis. 

Inguinal  adenitis  consists  almost  always  of  an  enlargement  of  the 
glands  which  rarely  suppurates  but  generally  undergoes  resolution. 

FOLLICULITIS,   PERIFOLLICULITIS,   PERIURETHRAL   ABSCESS. 

We  have  already  stated  that  the  glands  of  the  urethra  are  attacked  by 
the  gonorrhceal  process.  If  several  glands  are  thus  involved  they  can  be 
felt  from  without  as  small  bodies  about  the  size  of  a  hemp-seed.  They 
may  last  indefinitely  and  act  as  a  fresh  source  of  infection,  or  they  may 
degenerate  into  little  cysts,  or  if  their  surrounding  tissue  become  in- 
volved they  may  be  converted  into  small  periurethral  abscesses. 

This  is  typical  around  the  frsenum  where  the  glands  are  near  the 
external  surface.  Further  back  in  the  urethra  where  they  reach  into 
the  corpora  cavernosa  suppurations  can  extend  outward  as  easily  as 
inward,  so  that  the  final  result  is  often  a  urinary  fistula.  They  are 
much  less  common,  however,  than  periurethral  abscesses  near  the 
corona. 

PARAURETHRAL  FISTULA. 

Very  often  minute  openings  surrounded  by  a  zone  of  red  are  seen 
near  the  meatus.  Upon  pressure  pus  exudes,  in  which  gonococci  are 
usually  present.     These  paraurethral  or  periurethral  fistula?  are  blind, 


EXTRAGENITAL    COMPLICATIONS    OF    GONORRHOEA.  IOI 

that  is,  they  do  not  communicate  with  the  urethra.  They  may  con- 
tinue to  suppurate  for  a  long  time,  and  unless  they  are  destroyed  will 
prevent  cure  of  the  gonorrhoea. 

COWPERITIS  AND  PERICOWPERITIS. 

In  like  manner  the  gonorrhceal  process  may  invade  Cowper's  glands. 
If  marked  infiltration  occur  the  glands  can  be  felt  beneath  the  skin 
of  the  perineum  as  small  nodules  about  the  size  of  a  pea.  This 
infiltration  may  extend  to  the  surrounding  tissue.  It  may  be  entirely 
resorbed  or  it  may  suppurate;  in  the  latter  case  the  pus  is  usually 
absorbed,  although  rarely  it  works  its  way  to  the  exterior  and  produces 
a  urinary  fistula.  t 

[Chronic  inflammation  of  Cowper's  glands  is  sometimes  responsible 
for  chronic  relapsing  urethritis.  The  glands  can  be  palpated  through 
the  rectum  by  passing  the  index-finger  into  the  bowel  as  far  as  the 
apex  of  the  prostate,  then  withdrawing  it  slightly,  and  at  the  same 
time  making  lateral  pressure  on  the  perineum  with  the  thumb  so  as 
to  push  the  urethra  lateralwards.  The  glands  will  then  be  felt 
between  the  thumb  and  finger  as  small  nodules  about  the  size  of 
a  pea. 

The  treatment  of  this  condition  consists  in  massage,  which  must 
be  done  very  gently,  together  with  the  usual  measures  employed  for 
the  urethral  lesions.] 

The  other  complications  which  result  from  direct  extension  of  the 
infectious  process  are  cystitis,  urethritis,  pyelitis,  pyelonephritis, 
prostatitis,  deferenitis,  epididymitis,  orchitis,  and  spermatocystitis. 
(See  under  these  diseases). 

EXTRAGENITAL  COMPLICATIONS  OE  GONORRHOEA. 

Organs  winch  lie  more  or  less  remote  from  the  classical  seat  of  gonor- 
rhoea may  be  infected  by  the  gonorrhceal  virus  in  two  ways :  either  by 
direct  contact,  or  through  the  blood  or  lymph-channels  (gonorrhceal 
metastases).  Among  complications  arising  in  the  first  manner  may 
be  mentioned  gonorrhoea  of  the  rectum,  mouth,  nasal  cavities,  and  eye. 

Gonorrhoea  of  the  rectum  is  a  very  rare  disease.  The  gonococcus 
can  be  brought  to  the  rectum  by  indulgence  in  unnatural  sexual  prac- 
tices, or  in  the  uncleanly  it  may  infect  erosions  or  fissures  produced 
by  hemorrhoids  and  thus  gain  access  to  the  bowel.      Infection  of  the 


102  DISEASES    OF    THE    URETHRA    AND    PENIS. 

rectal  mucous  membrane  may  also  occur  when  a  gonorrhceal  abscess 
of  the  seminal  vesicles  or  prostate  ruptures  into  the  bowel  (Jadassohn). 

In  this  disease  the  mucous  membrane  around  the  anus  is  red  and 
excoriated.  The  discharge,  which  occurs  during  or  after  defecation 
and  also  independently  thereof,  is  malodorous  and  purulent,  or  perhaps 
sero-purulent  or  sanguinolent.  It  contains,  gonococci.  Fissures  and 
excoriations  form  on  the  anal  folds,  which  makes  defecation  painful; 
burning,  itching  of  the  anus,  and  rectal  tenesmus,  which  may  lead  to 
prolapse,  are  the  most  common  symptoms.  Small,  pointed  condylo- 
mata may  also  appear  at  the  anus. 

The  treatment  of  this  benign  disease  consists  in  scrupulous  cleanli- 
ness, sitz-baths,  injections  of  tannin,  alum,  or  potassium  permanganate, 
applications  of  zinc  ointment,  and  if  fissures  develop,  nitrate  of  silver 
ointment  or  the  fused  nitrate  of  silver. 

It  is  most  uncommon  for  the  gonococcus  to  infect  the  mucous 
membrane  of  the  mouth  and  nose,  although  cases  have  been  reported 
in  which  transmission  of  gonorrhoea  has  been  effected  by  dressings, 
handkerchiefs,  etc.  Buccal  gonorrhoea  is  also  said  to  have  occured  as  a 
metastasis.  The  most  plausible  view  is  that  infection  results  from 
unnatural  intercourse  with  a  man  suffering  from  gonorrhoea.  Kast 
has  reported  a  case  of  gonorrhoeal  stomatitis  occurring  in  an  infant. 
The  disease  was  mild  and  yielded  readily  to  frequent  astringent 
mouth  washes. 

Of  greater  importance  is  gonorrhceal  ophthalmia,  which  begins 
as  a  gonorrhoeal  inflammation  of  the  conjunctiva,  produces  a  purulent 
discharge  containing  gonococci,  and  often  leads  to  destruction  of  sight. 
It  occurs  in  the  new-born  as  well  as  in  adults. 

For  a  detailed  treatise  on  this  affection  the  reader  is  referred  to  text- 
books on  ophthalmology.  We  only  desire  to  call  attention  to  its 
seriousness.  The  inflammation  easily  extends  to  the  cornea  and  may 
partly  or  entirely  destroy  it  by  ulceration.  Every  case  of  gonorrhoeal 
ophthalmia  should  be  referred  to  an  ophthalmologist  for  treatment. 

Prophylaxis  of  the  disease  is  what  concerns  us.  We  must  impress 
our  patients  most  forcibly  with  the  danger  of  this  complication  and 
instruct  them  to  practice  the  most  scrupulous  personal  cleanliness, 
such  as  frequently  bathing  the  penis,  protecting  their  linen  by  means 
of  gauze  or  cotton  placed  over  the  meatus,  washing  the  hands  after 
urinating  or  using  an  injection,  etc. 

Crede's  admirable  method  of  touching  the  conjunctiva  with  2  per 


EXTRAGENITAL    COMPLICATIONS    OF    GONORRHOEA.  I  03 

cent  solution  of  silver  nitrate  immediately  after  birth  is  an  effectual 
preventive  of  gonorrhoea  neonatorum. 

Of  the  gonorrhoeal  metastases  the  most  important  and  most 
frequent  is  gonorrhoeal  arthritis. 

For  a  long  time  it  was  doubted  whether  a  true  gonorrhoeal  arthritis 
existed.  After  the  presence  of  the  gonococcus  in  the  joints  had  been 
demonstrated  beyond  cavil  by  means  of  pure  cultures  grown  from 
arthritic  effusions  there  was  no  further  room  for  difference  of  opinion. 
Gohn,  Schlagenhaufer,  Finger  and  others  have  demonstrated  gonococci 
in  the  secretion  of  the  joints  by  means  of  the  microscope,  have  grown 
them  on  culture  media,  and  studied  them  in  morbid  tissues.  It  must 
be  remembered,  however,  that  those  cases  in  which  gonococci  are  found 
in  the  exudate  are  not  the  only  ones  which  are  to  be  considered  as 
gonorrhoeal,  because  many  cases  in  which  the  specific  organism  is  not 
present  are  undoubtedly  of  gonorrhoeal  origin.  In  such  cases  micro- 
organisms of  suppuration  have  gained  access  to  the  joint  simulta- 
neously with,  or  subsequent  to,  its  invasion  by  the  gonococci  and 
destroyed  the  latter  organism.  These  are  examples  of  mixed  and 
secondary  infection,  respectively.  It  may  happen,  too,  that  the  gono- 
cocci perish  without  the  intervention  of  other  microorganisms. 

In  this  way  is  explained  the  so-called  germ-free  exudate  (or  accord- 
ing to  others  ptomaine  infection)  in  gonorrhoeal  joints. 

Gonorrhoeal  arthritis  occurs  in  about  2  per  cent  of  all  cases.  It 
may  develop  in  any  stage  of  the  disease,  although  its  incidence  is  most 
common  in  the  later  stages.  The  knee-joint  is  most  frequently  affected, 
the  ankle-joint  comes  second  and  the  joints  of  the  fingers  and  hands 
third.     Involvement  of  other  joints  is  rare. 

The  disease  begins  with  moderate  fever,  together  with  pain  and 
swelling  of  the  affected  joint.  The  exudate  increases  by  degrees  until 
it  becomes  profuse.  It  causes  distension  of  the  joint  which  impairs 
or  even  entirely  abolishes,  movement.  Fluctuation  is  generally  demon- 
strable. From  this  acute  stage  the  disease  passes  into  a  subacute 
condition.  The  fever  and  swelling  subside  and  the  exudate  becomes 
less,  being  often  completely  resorbed.  In  some  cases  acute  relapses 
follow  this  improvement.  The  disease  does  not  invariably  proceed  to 
resorption  of  the  exudate  and  restitutio  ad  integrum,  but  results  in  per- 
manent hydrarthrosis  or  terminates  in  suppuration. 

It  is  important  to  remember  that  gonorrhoeal  arthritis  is  often  of 
a  subacute  or  chronic  type  frcm  its  very  inception,  a  hydrarthrosis 


104  DISEASES    OF    THE    URETHRA    AND    PENIS. 

developing  gradually  without  any  premonitory  symptoms  or  pain, 
being  accompanied  only  by  swelling  and  impairment  of  function.  In 
such  cases  resorption  may  occur;  in  others  the  exudate  persists  and 
leads  to  plastic  changes  in  the  joint,  to  deformities  and  ankyloses 
which  interfere  partly  or  entirely  with  its  function. 

The  most  unfavorable  termination  of  all  is  suppuration.  It  may  per- 
sue  an  acute  or  chronic  course,  rupture  externally,  lead  to  ankylosis,  and 
also  to  fatal  pyaemia. 

Diagnosis  is  easy  in  most  cases,  true  rheumatism  being  the  only 
disease  from  which  gonorrhceal  arthritis  must  be  differentiated.  It  is  to 
be  remembered  that  when  gonorrhceal  arthritis  has  once  developed  as  a 
complication  it  has  a  tendency  to  recur  whenever  fresh  infection  is  con- 
tracted, and  that  only  a  few  joints  at  most  are  affected,  the  disease  often 
being  monarticular;  when  it  is  polyarticular  it  seldom  affects  more 
than  two  or  three  joints.  Moreover,  the  several  joints  are  not  involved 
simultaneously,  but  become  affected  one  after  another.  Furthermore, 
the  duration  and  intensity  of  the  subjective  symptoms  are  less  than  in 
articular  rheumatism;  fever  and  pain  subside  more  quickly, although  the 
joint  remains  swollen  and  its  function  is  impaired.  Oftentimes  in- 
creased intensity  of  the  articular  manifestations  occurs  simultaneously 
with  an  exacerbation  of  the  urethral  symptoms.  Finally  it  is  to  be  men- 
tioned that  gonorrhceal  arthritis  does  not  yield  so  promptly  to  specific 
treatment — salicylic  acid,  aspirin — as  does  articular  rheumatism; 
indeed,  it  may  be  said  that  these  remedies  have  absolutely  no  specific 
action  in  gonorrhceal  arthritis. 

The  prognosis  of  gonorrhceal  arthritis  is  not  unfavorable.  Its  pro- 
gress is  slow,  and,  as  above  stated,  it  may  terminate  in  permanent  hydra - 
throsis,  ankylosis,  or  suppuration;  generally,  however,  resolution  slowly 
but  surely  takes  place. 

Treatment  is  purely  symptomatic,  as  we  possess  no  specific.  Inter- 
nally oil  of  gaultheria  in  doses  of  ten  to  twenty  drops  three  times  a  day 
has  been  recommended,  as  have  also  potassium  iodide,  salol  and  anti- 
pyrin.  We  consider  the  best  treatment  to  be  immobilization  of  the  joint 
by  means  of  a  splint  and  bandages,  associated  in  the  later  stage  with 
inunctions  of  iodine  preparations,  local  hot-air  baths,  and  eventually 
sand  and  mud-baths. 

[Torrey's  antigonococcic  serum  has  been  used  with  apparent  success 
in  a  number  of  cases.  Further  experience,  however,  is  necessary 
before  its  exact  value  can  be  determined. 


EXTRAGENITAL   COMPLICATIONS    OF    GONORRHOEA.  105 

Bier's  passive  hyperemia  has  been  employed  with  some  success, 
although  it  is  said  not  to  shorten  the  duration  of  the  disease  (Hirsch). 
That  it  relieves  pain  in  many  cases,  however,  it  attested  by  the 
experience  of  several  surgeons  who  have  used  it. 

In  chronic  cases  tonics  are  indicated .  Full  doses  of  syrup  of  iodide 
of  iron  are  valuable;  arsenic  may  also  be  employed.  For  restoring 
motility  of  the  joint  massage  and  passive  movements  are  useful.  When 
suppuration  occurs  incise  the  joint,  irrigate,  and  drain,  the  same  as  in 
any  other  infective  arthritis. 

Gonorrhceal  ankylosis  of  the  wrist  has  recently  been  successfully 
treated  by  completely  resecting  the  carpus  and  interposing  a  muscular 
flap.  Good  motion  in  flexion  and  extension  and  also  ability  to  lift 
weights  has  been  obtained.  See  Nelatori's  paper  in  la  Revue  d'Orth- 
opcedie,  January,  1905.] 

Of  the  metastases  affecting  other  organs  and  tissues  we  will  first 
mention  gonorrhceal  tendovaginitis. 

This  is  a  relatively  rare  affection,  which  almost  never  occurs  before 
the  third  week  of  the  gonorrhoea,  and  which  begins  with  slight  febrile  dis- 
turbance and  pain  in  the  joints.  The  pain  is  confined  to  one  or  more 
tendon-sheaths,  which  appear  slightly  swollen  and  impart  a  sense  of 
fluctuation  when  palpated.  The  skin  over  them  is  somewhat  reddened 
and  cedematous.  Pressure  or  motion  increases  the  pain.  Usually  the 
pain  persists  after  the  swelling  and  redness  have  subsided.  Most  fre- 
quently the  tendons  and  tendon- sheaths  of  the  extensor  communis 
digitorum,  flexor  pollicis,  and  the  dorsal  extensors  of  the  toes  are  the 
ones  involved.  The  complication  is  not  serious  and  resorption  almost 
always  leads  to  cure;  relapses,  however,  are  frequent. 

Gonorrhceal  bursitis,  which  rarely  occurs  alone,  being  almost 
always  associated  with  disease  of  the  joints  or  tendon-sheaths,  is  a 
decidedly  benign  affection. 

Gonorrhceal  myositis  likewise  is  generally  a  complication  of 
arthritic  infection,  although  it  may  develop  independently  thereof. 
Cases  in  which  the  vastus  internus,  the  sterno-cleido-mastoid,  and  the 
trapezius  were  effected  with  rigidity,  tenderness  upon  pressure,  and 
impairment  of  function  have  been  reported.  With  a  single  recorded 
exception  resolution  and  cure  have  always  taken  place.  In  Eichhoff's 
case  sclerosis  of  the  affected  muscles  occurred. 

Gonorrhceal  periostitis  is  a  rather  more  common  complication  of 
gonorrhceal   arthritis.     A   classical    case    occurring  after  gonorrhoea! 


Io6  DISEASES    OF    THE    URETHRA    AND    PENIS. 

ophthalmia  has  been  reported  by  Ghon,  Schlagenhaufer  and  Finger. 
The  disease  is  manifested  by  circumscribed  elevated  swellings  on  the 
joint,  which  are  painful  and  sensitive  to  pressure.  The  skin  over  them 
is  doughy  and  cedematous.  The  periosteal  thickening  generally  under- 
goes resolution,  but  it  may  persist. 

Achillodynia  (pied  blennorrhagique)  is  the  name  given  to  a  perios- 
titis affecting  the  calcaneum  at  the  insertion  of  the  tendon  of  Achilles 
and  the  plantar  aponeurosis.  It  manifests  itself  as  a  painful  swelling 
below  the  insertion  of  the  tendon  and  interferes  with  walking.  Some- 
times there  is  also  a  cystic  enlargement  of  the  bursa  beneath  the 
calcaneum. 

Ullman  has  reported  a  case  of  acute  gonorrhoeal  osteomyelitis 
affecting  the  radius.  Pus  obtained  by  boring  into  the  bone  contained 
gonococci,  which  were  found  by  microscopic  examination. 

Gonorrhoeal  phlebitis  has  been  observed  by  Mertel  and  Batat,  the 
presence  of  the  specific  organism  being  demonstrated. 

As  to  complications  affecting  the  respiratory  system  cases  of  pulmon- 
ary infarct  have  been  known  to  follow  gonorrhoeal  arthritis  (Finger, 
Scholtz")  and  several  cases  of  pleurisy  have  been  observed.  In  Mazzas 
case  polyarthritis  developed  in  a  girl  aged  eleven  a  few  days  after 
she  had  been  raped,  and  a  double  pleurisy  immediately  followed  upon 
the  arthritis.  In  the  pleuritic  exudate  gonococci  were  found  micro- 
scopically and  also  by  culture. 

Special  importance  is  to  be  given  to  gonorrhoeal  affections  of  the 
nervous  and  circulatory  systems. 

The  peripheral  nerves  and  also  the  nerve-centers  may  be  affected. 
Fournier,  Lesser,  A.  Fraenkel  and  others  have  observed  ischialgia, 
Eulenberg  has  seen  neuralgia  of  gonorrhoeal  origin  in  areas  supplied  by 
the  sensory  nerves  of  the  arm,  and  Engel-Reimers  has  described 
similar  cases  in  the  region  of  the  ischiatic,  crural,  obturator,  and  auditory 
nerves;  Spillman,  Engel-Reimers,  and  Welander  have  observed  cases 
of  gonorrhoeal  polyneuritis. 

As  to  central  disturbances  von  Leyden's  description  of  transverse 
gonorrhoeal  myelitis  has  become  authoritative.  The  symptoms  are 
muscular  atrophy,  pain,  hyperae:thesia  of  the  extremities,  increased  re- 
flexes, neuralgia,  pain  in  the  spinal  column,  a  sense  of  constriction 
around  the  body  (girdle  pain),  and  disturbances  of  micturition.  Ex- 
amination of  the  spinal  cord  in  von  Leyden's  case  revealed  only  slight 
evidences  of  myelitis  in  comparison  with  the  severe  nervous  symptoms 


EXTRAGENITAL    COMPLICATIONS    OF    GONORRHCEA.  1 07 

which  were  present  during  life.  Gonococci  were  not  found  in  the 
spinal  nerves.  This  case  teaches  us  that  even  severe  gonorrhceal  spinal 
myelitis  and  myelo-meningitis  may  be  cured. 

Litten  has  reported  two  cases  of  post  gonorrhoeal  chorea. 

Gonorrhceal  endocarditis.  Within  the  last  decade  it  has  been 
positively  determined  that  gonorrhoea  can  produce  cardiac  metastases. 
Von  Leyden  first  described  a  case  of  genuine  gonorrhceal  endocar- 
ditis. In  the  vegetations  he  found  microorganisms  which  in  form, 
size,  arrangement  and  staining  reaction  possessed  the  attributes  of  the 
gonococcus,  although  cultures  could  not  be  grown.  Later  Lenhartz, 
Ghon,  Schlagenhaufer  and  Finger  described  cases  in  which  the 
gonorrhceal  nature  of  the  endocarditis  seemed  assured,  and  in 
which  gonococci  in  pure  culture  were  obtained  from  the  ulcerated 
endocardium.  In  the  case  of  Ghon  and  Schlagenhaufer  an  acute 
gonorrhoea  was  produced  by  inoculating  the  urethra  with  the  culture 
thus  obtained. 

The  endocarditis  which  develops  in  gonorrhoea  generally  as  a  com- 
plication of  arthritis,  but  also  independently  thereof,  is  therefore  a  true 
gonorrhceal  metastasis,  although  of  course  a  similar  condition  may 
be  produced  by  mixed  or  secondary  infection. 

There  are  two  forms,  a  benign  and  a  malignant.  The  first  begins 
without  elevation  of  temperature,  only  slight  cardiac  disturbance, 
irregular  pulse,  palpitation  and  a  feeling  of  oppression  being  present. 
Upon  auscultation  murmurs  are  heard.  The  symptoms  either  subside 
rapidly  under  rest-treatment  or  become  accentuated  and  lead  to  a 
valvular  lesion  and  its  sequelae.  The  malignant  form,  which  almost 
without  exception  is  preceded  or  accompanied  by  gonorrhceal  arth- 
ritis, is  ushered  in  by  chilis  and  high  fever.  The  sensorium  is  be- 
numbed. Anxiety,  a  sense  of  oppression,  dyspnoea,  rapid  pulse, 
loud  cardiac  murmurs,  albuminuria  and  polyuria  are  the  principal 
symptoms. 

Remissions  occur  but  they  are  soon  followed  by  exacerbations.  The 
disease  terminates  either  in  death  or  in  an  incurable  cardiac  lesion. 
Death  is  caused  by  embolism,  infectious  nephritis,  or  by  extension  of 
the  morbid  process  to  the  heart  muscle  (acute  myocarditis).  Pericar- 
ditis and  multiple  metastases  are  almost  always  present;  thrombi  are 
found  in  the  spleen,  kidneys  and  brain.  Microscopic  examination  of 
the  endocardial  vegetations  reveals  gonococci,  pyogenic  bacteria 
(secondary  infection),  or  both  (mixed  infection). 


108  DISEASES    OF    THE    URETHRA    AND    PENIS. 

The  prognosis  of  the  benign  form  is  good,  that  of  the  malignant 
form  bad;  in  the  most  favorable  cases  of  the  latter  form  a  permanent 
cardiac  lesion  results. 

The  treatment  does  not  differ  from  that  of  other  forms  of 
endocarditis. 

In  addition  it  may  be  mentioned  that  post-gonorrhceal  septicaemia, 
though  exceedingly  rare,  has  certainly  been  observed.  The  patients 
suffer  from  protracted  fever  with  evening  elevation  of  temperature  as 
high  as  40.50  C.  (1050  F.)  The  enlargement  of  the  spleen  and  icteric 
discoloration  of  the  sclera  leave  no  doubt  as  to  the  nature  of  the  malady, 
although  as  yet  the  presence  of  gonococci  in  the  blood  has  not  been 
positively  demonstrated.  It  is  also  an  open  question  whether  mixed 
or  secondary  infection  with  the  organisms  of  suppuration  takes 
place. 

Exanthemata  in  gonorrhoea.  Formerly  when  eruptions  occurred 
daring  or  after  gonorrhoea  they  were  attributed  to  the  medicines 
which  had  been  used,  as  for  example,  balsam  of  copaiba.  It  was 
found  out,  however,  that  occasionally  an  exanthema  may  develop 
in  cases  in  which  no  drugs  are  administered.  Therefore  it  may  be 
assumed  that  there  is  a  causative  relation  between  gonorrhoea  and 
these  dermatoses. 

Up  to  the  present  time  no  one  has  succeeded  in  finding  gonococci 
either  in  the  blood  of  patients  having  the  eruptions  or  in  the  skin  lesions 
themselves.  Vidal  and  Besnier  consider  them  to  be  trophic  myelo- 
pathic toxicodermata.  Buschke  believes  that  they  are  the  result 
of  the  gonorrhceal  toxin.  They  appear  in  the  form  of  erythema, 
herpes,  urticaria,  purpura  and  hyperkeratoses,  the  palms  of  the  hands 
and  soles  of  the  feet  being  their  most  common  site,  although  they  affect 
other  parts,  as  for  example,  the  thighs  and  genitalia. 

Having  now  discussed  the  complications  of  gonorrhoea  we  will 
proceed  to  the  consideration  of  its  prognosis  and  therapy. 

The  prognosis  as  to  life  is  good.  It  is  only  with  the  greatest  rarity 
that,  as  the  result  of  blood-infection,  a  severe  complication  such  as 
endocarditis  develops  and  endangers  life. 

The  prognosis  as  to  recovery  is  doubtful.  A  small  percentage  of 
acute  cases  get  entirely  well;  the  majority,  however,  become  chronic. 
As  a  rule,  chronic  gonorrhoea  can  be  converted  by  protracted  treatment 
into  the  simple  non-infectious  urethritis,  but  even  then  we  cannot  in 
the  strictest  sense  consider  it  cured,  inasmuch  as  the  chronic  catarrhal 


TREATMENT    OF    URETHRITIS.  IO9 

process  lasts  for  years  or  tens  of  years,  and  generally  the  complica- 
tions which  it  produces  by  extension — as  for  instance  prostatitis — also 
persist. 

Furthermore  it  is  to  be  borne  in  mind  that  as  long  as  the  chronic 
process  remains,  sudden  exacerbations  may  occur,  and  that  the 
catarrhal  condition  affords  a  good  soil  for  the  growth  of  bacteria,  which 
may  cause  ascending  affections  such  as  cystitis  or  pyelitis  to  develop, 
even  though  gonococci  be  no  longer  present.  Gonorrhoea,  therefore, 
is  a  serious  disease  which  requires  careful  attention  on  the  part  of  the 
physician. 

TREATMENT. 

The  first  and  most  important  thing  to  be  enjoined  upon  a  man 
suffering  from  gonorrhoea  is  the  practice  of  scrupulous  cleanliness.  He 
must  be  warned  of  the  danger  of  conveying  infection  with  the  purulent 
discharge  and  especially  against  carrying  it  to  his  eyes.  He  should 
bathe  several  times  a  week  and  wash  the  penis,  after  drawing  the  pre- 
puce back,  three  times  a  day,  and  afterwards  cover  it  with  cotton  in 
order  to  prevent  the  discharge  from  contaminating  his  linen  and  thus 
furnishing  a  constant  source  of  infection. 

Coitus  is  of  course  forbidden.  The  patient  should  wear  a  suspensory 
bandage  and  avoid  all  severe  bodily  effort,  especially  gymnastic  exer- 
cises, riding,  bicycling,  swimming,  etc. 

He  should  partake  of  a  mild,  unirritating  diet.  All  highly  seasoned 
and  sour  foods,  herring,  radishes,  salads,  mustard,  spiced  sauce, 
smoked  and  salted  meats,  cheese,  and  all  alcoholic  beverages  are  to 
be  interdicted.  As  patients  are  usually  obliged  by  social  reasons  to 
conceal  their  disease,  they  may  be  permitted,  when  it  becomes  necessary, 
to  drink  a  little  red  wine  mixed  with  water,  this  being  the  least  harmful 
alcoholic  beverage  of  which  they  can  partake. 

During  the  acute  stage  large  quantities  of  water  should  be  drunk,  so 
that  frequent  urination  will  be  produced  and  the  pus  washed  out  of 
the  urethra.  I  allow  as  much  as  6  liters  (12.6  pints)  of  water  to  be 
drunk  daily.  Mineral  waters,  such  as  manufactured  soda-water, 
Fachinger,  Sauerbrunnen,  etc.,  have  been  decried  as  injurious.  I  have 
never  observed  any  harmful  action  from  them,  and  prescribe  them  as 
diuretics. 

Of  internal  remedies  the  balsamics  and  diuretics  are  the  only  ones 
posessing  any  value;  the  antiseptics,  such  as  boric  acid,  salol,  etc., 


HO  DISEASES    OF    THE    URETHRA    AND    PENIS. 

have  proved  useless.  Vegetable  diuretics  in  the  form  of  tea  taken 
several  times  a  day,  oil  of  sandalwood,  balsam  of  copaiba,  fluid  extract 
of  pichi  in  doses  of  20  to  40  drops  daily  are  appropriate  drugs,  especially 
in  those  cases  in  which  inflammatory  symptoms  or  strangury  are 
present.     The  balsams  may  be  given  in  the  following  prescription: — 

P^      Ol.  santali  (or  Bals.  copaibae) 
Ext.  pichi  fl.  aa  15.0  (f3-  iv.) 
01.  menth.  pip.  gtt.  v. 
m 
Sig.     20  drops  three  times  daily. 

Oil  of  sandalwood  or  balsam  of  copaiba  may  also  be  given  alone  in 
capsules  containing  0.5  (7-?,  minims),  of  which  from  1  to  3  three  times 
a  day  may  be  taken. 

The  action  of  these  drugs  must  be  watched,  because  they  sometimes 
produce  gastritis  and  also  irritate  the  kidneys.  In  such  cases  they 
must  be  immediately  stopped. 

For  painful  erections  large  doses  of  the  bromides  may  be  given  or 
heroin  in  doses  of  0.004  to  0.006  (^ — ^  gr.)  may  be  used  instead. 
Cold  applications  to  the  penis,  cool  sitz-baths,  regulation  of  the  bowels, 
and  avoidance  of  late  suppers  are  useful  measures. 

In  lymphangitis  it  is  well  to  bind  the  penis  to  the  abdomen  and  apply 
a  3  per  cent  solution  of  aluminum  acetate  or  lead  water. 

As  to  local  treatment  it  is  first  to  be  borne  in  mind  that  uncomplicated 
gonorrhoea  is  a  trivial  disease,  but  that  complications  frequently  convert 
it  into  a  serious  malady,  the  consequences  of  which  cannot  be  foretold  ; 
furthermore,  it  must  be  remembered  that  injudicious  local  treatment 
frequently  causes,  or  at  least  favors  the  development  of  these  complica- 
tions. Therefore,  if  the  complications  are  more  serious  and  dangerous 
than  the  original  disease  itself,  it  seems  logical  to  conclude  that,  if 
possible,  treatment  must  so  be  conducted  as  to  prevent  their 
supervention. 

Acting  in  accordance  with  this  principle  I  have  come  to  abandon 
under  all  circumstances  the  abortive  treatment  of  gonorrhoea,  of 
which  I  have  essayed  four  kinds,  namely;  instillations  of  2  per  cent 
silver  nitrate  solution  with  Guyon's  apparatus;  injections  of  a  f  per 
cent  protargol  solution;  irrigation  of  the  urethra  according  to  Janet's 
method  with  potassium  permanganate  solution,  and  irrigation  with 


TREATMENT    OF    URETHRITIS.  Ill 

weak  silver  solutions.     In  not  a  single  case  was  the  disease  aborted; 
the  morbid  process  already  begun  pursued  its  course. 

This  ineffectiveness  will  not  cause  surprise  if  we  stop  to  consider  that, 
while  the  symptoms  of  gonorrhoea  usually  manifest  themselves  several 
days  after  exposure,  the  gonococci  penetrate  the  upper  surface  of  the 
urethral  mucous  membrane  within  a  few  hours  after  infection  takes 
place.  Abortive  methods  then  offer  a  prospect  of  success  only  when 
they  can  be  applied  before  penetration  occurs.  This  may  be  possible 
in  exceptional  instances,  but  the  majority  of  cases  will  not  be  favorably 
influenced.  Even  granting  that  in  this  or  that  case  results  might  be 
expected  from  the  abortive  treatment  still  I  would  not  resort  to  its  em- 
ployment because  I  believe  it  subjects  the  patient  to  too  great  risk.  I 
have  observed  great  harm  result  from  its  use,  having  seen  cases  of  lym- 
phangitis, lymphadenitis,  prostatitis  and  cystitis  develop  in  such  a  way 
as  to  leave  no  doubt  that  treatment  and  complications  bore  the  relation 
of  cause  and  effect.  While  these  complications  in  themselves  may  not 
be  dangerous  their  results  are  incalculable.  As  the  abortive  method 
is  uncertain,  and  as  the  customary  and  more  protracted  methods  of 
treatment  offer  prospect  of  success  in  the  majority  of  cases,  I  believe 
the  plan  of  abandoning  every  abortive  method  to  be  well-founded. 

For  like  reasons  care  must  be  taken  not  to  begin  instrumental  treat- 
ment of  gonorrhoea  too  early.  If  instruments  be  introduced  while  a 
florid  discharge  rich  in  gonococci  is  present,  the  danger  of  producing  in- 
fection in  parts  which  have  thus  far  remained  free  will  be  incurred. 
This  applies  not  only  to  acute  gonorrhoea,  but  also  to  chronic  which  for 
any  reason  has  become  exacerbated  and  so  resembles  the  acute  form, 
in  such  cases  the  indication  is  to  continue  injections  until  both  the 
amount  and  virulence  of  the  discharge  have  been  lessened.  The  only 
exceptions  to  this  rule  are  cases  in  which  the  passage  of  an  instrument 
cannot  possibly  be  avoided,  as  for  example,  retention  of  urine  which  can- 
not be  relieved  in  any  other  way. 

Relative  to  the  treatment  of  acute  gonorrhoea  it  is  to  be  remembered 
first  of  all  that  the  gonococci  thrive  better  in  inflamed  tissues  than 
they  do  in  tissues  free  from  inflammation — a  fact  which  daily  experience 
teaches  us.  The  greater  number  of  gonococci  are  found  in  the  early 
stages  when  inflammation  is  at  its  height.  With  progressive  improve- 
ment and  diminution  of  inflammation  the  discharge  becomes  less  and 
the  number  of  gonococci  diminish.  Let  an  exacerbation  occur,  so  that 
pain  returns, together  with  swelling  and  redness  of  the  meatus, and  the 


112  DISEASES    OF    THE    URETHRA    AND    PENIS. 

gonococci  almost  always  increase.  These  observations  led  the  older 
physicians  to  refrain  from  using  injections  during  the  inflammatory 
stage  and  to  wait  until  the  acuteness  of  the  attack  had  subsided.  They 
possessed  the  correct  idea  that  irritation  of  the  urethra  aggravated  the 
disease. 

In  addition  to  the  kind  of  gonorrhoea  which  we  have  just  described 
there  is  a  form  in  which  all  inflammatory  symptoms  are  absent  from  the 
beginning.  Neither  pain  nor  swelling  and  redness  are  present,  there 
being  only  a  purulent  discharge  containing  gonococci. 

In  both  forms  I  recommend  injections  from  the  very  beginning. 
When  we  consider  that  we  are  dealing  with  a  local  infection  it  is  correct 
to  endeavor  to  expel  the  infecting  germs  from  their  local  foci.  The  only 
objection  to  this  method  is  the  danger  of  carrying  the  microorganisms 
into  unaffected  portions  of  the  genito-urinary  tract.  We  must  of  course 
endeavor  to  prevent  such  an  occurrence.  The  patients  should  use  their 
injections  only  after  urinating,  and  in  order  that  the  urethra  may  be 
thoroughly  cleansed  by  the  stream  of  urine  they  should  take  large  quan- 
tities of  liquids,  which  will  make  them  pass  their  water  frequently.  I 
order  from  4  to  6  1.  (8  to  12  pints)  of  fluid  a  day;  water,  milk,  car- 
bonated waters,  tea,  and  infusions  of  diuretic  herbs  may  be  pre- 
scribed. 

The  injections  used  in  the  inflammatory  form  of  gonorrhoea  must  be 
absolutely  unirritating ;  irritant  injections  which  increase  or  produce 
inflammation  are  to  be  excluded.  The  best  of  the  non-irritant  remedies 
is  a  1  per  cent  solution  of  thallin  sulphate,  which  was  recommended  by 
Goll  many  years  ago.  It  has  a  specific,  antigonorrhceic  and  antiseptic 
action,  reducing  inflammation  and  checking  the  discharge.  Under  its 
use  the  gonococci  rapidly  decrease  in  number  and  the  thick,  yellow,  pro- 
fuse pus  soon  becomes  converted  into  a  scanty  muco-purulent  or  mucoid 
secretion.  The  injections  should  be  taken  as  often  as  possible,  at  least 
from  six  to  eight  times  a  day. 

There  are  cases  in  which  thallin  fails ;  in  such,  very  weak  solutions 
of  potassium  permanganate  (1 :  icooo-i  :  8000.)  or  a  1  per  cent  solu- 
tion of  resorcin  may  be  substituted.  Their  action  though  similar  to 
that  of  thallin  is,  as  a  rule,  not  so  prompt  and  efficient. 

After  a  few  days  of  this  treatment  the  inflammatory  symptoms  will 
have  abated  and  the  only  evidence  of  disease  will  be  a  thin  muco-puru- 
lent discharge  containing  gonococci ;  in  other  words  it  will  be  the  same 
as  the  non-inflammatory  form  at  its  inception.     At  this  time  a  modified 


TREATMENT    OF    URETHRITIS.  I  IT, 

form  of  the  well-known  antiseptic  treatment  with  various  salts  of  silver 
may  be  instituted. 

In  my  opinion  the  best  antiseptic  injection  is  the  oldest  one,  namely, 
silver  nitrate.  At  first  it  should  not  be  used  stronger  than  i :  ioooo, 
but  it  can  be  gradually  increased  in  strength  up  to  i :  4000.  In  many 
cases  even  these  weak  solutions  produce  pain  and  irritation.  In  such 
cases  I  discontinue  their  use  and  employ  protargol  in  the  strength  of  £ 
per  cent,  gradually  increasing  to  1  per  cent.  This  drug  apparently  has 
a  less  irritating  effect.  I  say  apparently,  because  while  it  is  less  painful 
and  not  so  irritating  as  silver  nitrate,  it  increases  the  discharge  the  same 
as  the  latter  salt. 

The  fact  that  both  these  silver  preparations  have  an  irritating  action 
and  increase  the  discharge  has  induced  me  never  to  employ  them  alone, 
but  instead  to  use  in  association  with  them  injections  which  diminish 
secretion  and  control  irritation ;  in  this  modification  lies  the  value  of  the 
treatment.  The  patients  are  directed  to  use  these  injections,  using  dur- 
ing the  first  period  nitrate  of  silver  or  protargol  with  thallin,  perman- 
ganate of  potassuim,  or  resorcin ;  during  the  second,  silver  and  zinc  (zinc 
sulphate  1 :  icoo-i  :  250);  and  during  the  third,  when  the  morbid  process 
is  near  its  end,  potassium  permanganate  and  zinc.  The  gonococci  will 
be  most  vigorously  assailed  by  the  silver  preparations,  but  the  discharge 
will  be  increased;  the  potassium  permanganate  used  afterwards  will  over- 
come the  increased  secretion.  Then  the  silver  is  used  again  and  is  again 
followed  by  the  permanganate.  The  injections  should  be  taken  at  least 
six  times  daily,  the  oftener  the  better,  as  Unna  has  well  demonstrated. 

An  endeavor  has  been  made  to  meet  both  indications  by  a  single 
remedy,  namely,  zinc  hypermanganate,  in  which  the  permanganate  is 
supposed  to  destroy  gonococci  and  the  zinc  to  exert  an  astringent  effect. 
I  have  found  that  both  drugs  work  better  when  used  separately. 

Acetate  of  lead  in  the  strength  of  1  grain  to  the  ounce  and  bismuth  sub- 
nitrate  15  grains  to  the  ounce  are  also  good  astringents ;  copper  and  alum 
are  not  so  valuable.  In  order  to  make  these  injections  more  tenacious 
from  31,,  to  I  their  volume  may  be  composed  of  mucilage  of  acacia 
or  glycerine. 

Rest,  diet,  and  the  use  of  diuretics  and  balsamics  in  the  manner 
previously  recommended  are  valuable  auxiliary  measures. 

The  results  obtained  by  this  method  are  on  the  whole  very  satis- 
factory. Generally  the  disease  will  be  cured  in  four  or  five  weeks,  so 
that  neither  discharge  nor  shreds  in  the  urine  can  be  detected.     A 


ii-l  DISEASES    OF    THE    URETHRA    AND   PENIS. 

tiling  of  much  more  importance  and  one  which  we  designated  as  being 
most  desirable  at  the  beginning  of  our  remarks  on  treatment  is  the 
rarity  of  complications  under  this  regimen. 

[The  treatment  of  acute  posterior  urethritis  varies  somewhat  with 
its  mode  of  onset.  In  cases  in  which  involvement  of  the  posterior 
urethra  manifests  itself  by  sudden  onset  of  the  violent  local  and 
constitutional  symptoms  already  referred  to,  the  patient  should  be 
put  to  bed,  given  a  brisk  saline  purge,  placed  on  liquid  or  soft  diet,  and 
ordered  a  hot  sitz  bath  night  and  morning.  Local  treatment  of  the 
anterior  urethra  should  be  immediately  stopped,  as  experience  has 
shown  that  patients  do  better  when  the  urethra  is  let  entirely  alone 
than  when  antiseptic  injections  are  employed. 

Narcotics  are  always  required  to  control  the  frequent  and  painful 
micturition.  Opium  and  belladonna  hold  the  first  rank.  They  may 
be  given  hypodermatically,  internally,  or  per  rectum.  For  the 
severest  cases  £  gr.  of  morphine  and  Ti^  gr.  of  atropine  maybe  injected 
hypoilermatically  twice  or  thrice  in  twenty-four  hours.  As  a  rule, 
however,  the  use  of  opium  and  belladonna  suppositories  will  be 
found  efficacious.  A  suppository  containing  one  grain  each  of 
powdered  opium  and  extract  of  belladonna  may  be  inserted  into  the 
rectum  every  three  or  four  hours  until  relief  is  obtained  or  the  safe  limit 
of  physiological  action  of  the  drugs  is  reached.  I  frequently  employ  a 
suppository  containing  two  grains  of  the  extract  of  hyoscyamus,  which 
seems  particularly  potent  in  controlling  tenesmus.  A  mild  alkaline 
diuretic  should  be  given  internally,  and  if  desired  a  narcotic  may  be 
combined  with  it.     The  following  mixture  will  be  found  useful. 

1^.     Potassii  acetatis  5  lv- 

Tr.  hyoscyami  f§  iss. 

Spts.  aetheris  nitrosi  q.  s.  ad  f  §  hi. 
Sig.  Teaspoonful  in  water  every  three  hours. 

Other  drugs  which  have  been  employed  in  this  condition  are  oil  of 
sandalwood,  in  the  dose  of  five  minims  every  four  hours;  urotropin, 
in  the  dose  of  7^  grains  three  times  a  day;  salol;  boric  acid;  and  the 
stimulating  vegetable  diuretics,  such  as  buchu  and  uva  ursa.  I 
have  tried  each  and  every  one  of  these  drugs  and  have  failed  to 
obtain  any  better  results  from  them  than  from  a  simple  alkaline 
diuretic.     Sandalwood  and  buchu  are  probably  the  best  in  the  list. 


ERRATA. 

Page  115,  line  12:    for  "one  per  cent."  read  "one-tenth 
per  cent." 

Page   116,  line   12:  for  "i%"  read  "0.1%." 


TREATMENT    OF    URETHRITIS.  I  I  5 

Urotropin  has  failed  me  entirely,,  and  in  some  instances  has  seemed 
to  aggravate  the  symptoms. 

If  desired  the  mixture  above  mentioned  may  be  given  in  the  infusion 
of  buchu  instead  of  water.  It  may  be  necessary  to  use  opium  sup- 
positories in  conjunction  with  it. 

Usually  a  few  days  of  this  regimen  will  so  reduce  the  severity  of  the 
symptoms  that  local  treatment  may  be  resorted  to.  This  will 
consist  in  the  employment  of  one  of  three  measures: — 

1.  Instillations  of  five  to  twenty  minims  of  a  one  or  two  per  cent 
solution  of  silver  nitrate  into  the  posterior  urethra  by  means  of  the 
Keyes-Ultzmann  syringe;  2.  irrigation  of  the  posterior  urethra 
and  bladder  with  three  to  six  fluid  ounces  of  a  one  per  cent  solution 
of  silver  nitrate,  after  the  method  of  Diday,  with  a  soft  rubber  catheter 
and  hand  syringe;  3.  irrigation  of  the  anterior  and  posterior  urethra 
and  bladder  with  hot  permanganate  solution,  beginning  with  1-8000 
and  gradually  increasing  the  strength.  Of  these  three  procedures 
the  silver  irrigations  have  given  me  the  best  results.  The  exact 
technic  of  this  procedure  will  be  found  on  page  116,  under  the  treat- 
ment of  gonorrhceal  cystitis. 

In  those  cases  in  which  posterior  involvement  develops  gradually, 
in  which  tenesmus  and  strangury  are  only  moderate,  and  consti- 
tutional symptoms  mild  or  absent,  recourse  may  be  had  at  once  to 
local  treatment.  For  patients  thus  affected,  hot  permanganate 
irrigations,  after  the  method  of  Janet,  given  morning  and  evening, 
or  even  once  a  day,  will  be  found  very  effectual.  They  must  not, 
however,  be  given  under  strong  pressure.  When  the  subjective 
symptoms  subside  a  few  silver  irrigations  may  be  required  to  clear 
up  the  turbidity  of  the  second  portion  of  the  urine.  Silver  may  be 
used  from  the  very  beginning  of  the  treatment  if  preferred,  being 
given  on  alternate  days. 

In  this  form  of  the  disease  narcotics  will  also  be  required,  but  they 
may  be  used  in  smaller  quantities  than  in  the  hyperacute  form. 
Usually  the  internal  administration  of  belladonna  or  hyoscyamus, 
with  an  opium  suppository  at  bedtime  will  suffice.  A  balsamic  or  an 
alkaline  diuretic  may  also  be  used.  In  this  class  of  cases,  too,  some 
surgeons  allow  the  patient  to  use  hand  injections  of  weak  antiseptics, 
such  as  potassium  permanganate,  protargol,  and  albargin.  I  have 
occasionally  followed  this  course  myself,  but,  as  a  rule,  particularly 
one  to  be  observed  by  the  general  practitioner,  I  believe  it  better 


Il6  DISEASES    OF    THE    URETHRA    AND    PENIS. 

that  all  local  treatment,  except  that  administered  by  the  doctor  him- 
self, should  be  stopped.] 

The  same  principles  should  guide  us  in  the  treatment  of  acute 
gonorrhceal  cystitis,  which  often  begins  as  a  cystitis  colli. 

Experience  teaches  that  many  of  these  cases  get  well  under  rest, 
diet,  narcotics,  and  liberal  use  of  diluent  drinks.  If  after  reasonable 
trial  of  these  measures  the  urine  does  not  clear  up,  but  remains  turbid  as 
to  its  second  portion,  I  resort  to  irrigations  after  the  method  of  Diday, 
which  was  also  later  practised  and  taught  by  Ultzmann.  A  thin 
French  olivary  catheter  (Fig.  124),  or  Ultzmann's  irrigating  catheter 
(Fig.  125),  is  passed  down  to  the  beginning  of  the  membranous  urethra, 
and  from  100  to  200  ccm.  (3  to  6  fluid  ounces)  of  a  1  per  cent  silver 
nitrate  solution  injected  through  the  posterior  urethra  into  the  bladder 
by  means  of  a  hand- syringe.  As  the  anterior  urethra  is  almost  always 
affected  it  should  also  be  irrigated.  For  this  purpose  the  catheter  is 
drawn  forward  a  few  centimeters  so  that  its  eye  lies  in  the  bulb  of  the 
urethra  and  then  the  silver  solution  is  injected.  It  flows  out  between 
the  catheter  and  the  urethra.  During  the  injection  it  is  well  to  press 
the  lips  of  the  meatus  together  at  short  intervals  so  as  to  distend  the 
urethra  and  thereby  force  the  medicated  fluid  into  all  its  nooks  and 
crannies.  This  procedure  usually  works  like  magic;  strangury,  pain 
and  haemorrhage  quickly  subside  and  the  urine  rapidly  becomes 
clear.  The  injections  are  given  every  second  day;  in  the  intervals  the 
patient  uses  weak  unirritating  injections  of  thallin  or  potassium 
permanganate   1 :  10000-1 :  6000. 

Care  must  be  taken  not  to  employ  this  procedure  too  early,  as  it 
may  then  favor  the  development  of  epididymitis  or  prostatitis;  if  we 
delay  too  long,  though,  care  must  be  taken  lest  extension  of  the  process 
to  the  ureters  and  pelvis  of  the  kidneys  be  furthered.  In  general, 
however,  the  latter  accident  is  of  less  frequent  occurrence  than  the 
former,  and  therefore  it  is  less  injurious  and  less  dangerous  to  wait 
too  long  before  resorting  to  this  local  treatment  than  to  begin  it  too 
early. 

If  other  indications  are  present  they  must  of  course  be  met.  In 
lymphangitis  the  penis  must  be  kept  at  rest  and  cold  dressings  applied. 
Periurethral  abscesses  must  be  opened.  Periurethal  or  paraurethral 
fistulae  must  be  destroyed  or  excised.  Generally  is  suffices  to  cauterize 
them  with  a  fine  thermocautery. 

We  come  now  to  consider  the  treatment  of  chronic  gonorrhoea 


TREATMENT    OF    URETHRITIS 


117 


and  urethritis.  By  the  term  chronic  gonorrhoea  is  meant  a  catarrhal 
discharge  in  which  gonococci  are  present,  whereas  the  term  urethritis 
is  applied  to  a  similar  condition  in  which  gonococci  are  no  longer  found. 


Fig.  124. — Irrigation  after  the  method  of  Diday. 


It  is  desirable  to  make  certain  discriminations  in  this  disease  of 
multiform  manifestation  and  to  be  guided  therein  solely  by  practical 
considerations. 


ir8 


DISEASES    OF    THE    URETHRA    AND    PENIS. 


Frequently  met  with  and  most  grateful  for  a  properly  conducted 
course  of  therapy  are  those  subjects  of  chronic  urethral  catarrh 
who,  despite  months  of  treatment  with  every  conceivable  injection, 
remain  uncured.  In  the  discharge  gonococci  may  or  may  not  be 
present.  The  reason  why  these  patients  do  not  get  well  is  because 
the  morbid  process  has  established  itself  in  places  which  the  usual 
injections  used  by  the  patients  themselves  cannot  reach,  that  is,  in  the 
posterior  urethra,  which  in  the  vast  majority  of  cases  is  affected,  and 
in  the  upper  layers  of  the  submucosa.  For  these  cases  instillations  after 
the  method  of  Guyon,  or  irrigations  as  recommended  by  Janet  are 
excellent  measures.  For  instillation  a  i  or  2  per  cent  solution  of  silver 
nitrate  should  be  used;  for  irrigation  a  1:5000-1:1000  solution  of 
potassium  permanganate;  or  silver  solution  in  the  strength  of  1:10000- 
1 :  2000,  may  be  employed  alternately  with  the  permanganate. 


Fig.  125. — Ultzmann's  irrigating  catheter. 


-■&- 


Fig.  126. — Guyon's  instillating  syringe  with  catheter  attached. 

By  the  use  of  instillations  a  few  drops  of  concentrated  medicinal  solu- 
tion may  be  brought  to  every  part  of  the  urethra.  A  syringe  (Fig.  t  26), 
holding  about  10  ccm.  (approximately  2\  fluid  drachms)  is  connected 
to  a  long  olivary  catheter  by  means  of  a  hard  rubber  canula,  and  after  a 
little  of  the  fluid  has  been  forced  to  the  eye  of  the  catheter  the  instru- 
ment is  introduced  as  far  as  the  sphincter  vesicae;  then  by  simultan- 
eously withdrawing  the  catheter  and  pressing  on  the  piston  of  the 
syringe  the  fluid  is  forced  out  drop  by  drop.  If  it  be  desired  to  ca  uterize 
the  posterior  urethra  begin  at  the  neck  of  the  bladder;  if  the  anterior 
urethra,  begin  at  the  bulb.  Occasionally  the  tip  of  the  catheter  will 
not  pass  over  the  bulb  even  though  no  stricture  be  present.  This  is 
due  to  spasmodic  contraction  of  the  compressor  urethras  muscle. 
For  such  cases  the  Keyes-Ultzmann  instillating  syringe  (Fig.  127)  is 
suitable  as  it  also  expels  the  fluid  drop  by  drop.  With  this  instrument 
a  \-2  per  cent  solution  of  silver  nitrate  is  generally  used. 


TREATMENT    OF    URETHRITIS. 


ti$ 


In  Janet's  irrigation  method  the  fluids  already  mentioned  are  forced 
into  the  urethra  with  an  irrigator,  which  is  placed  at  variable  heights 
above  the  patient.  At  first  \  liter  (i  pint)  is  allowed  to  run  into  the 
anterior  urethra,  then  from  \  to  \  liter  {\  to  i  pint)  is  forced  into 
the  posterior  urethra.  When  it  is  desired  to  irrigate  the  anterior 
urethra  a  conical  glass  nozzle,  attached  to  the  tube  of  the  irrigator,  is 
inserted  in  such  a  manner  that  the  fluid  can  flow  out  between  it  and  the 
wal's  of  the  urethra.  To  irrigate  the  posterior  urethra  the  nozzle  is 
he'.d  firmly  against  the  meatus  and  the  irrigator  raised  somewhat  higher, 
say  about  i  to  \\  m.  (3  to  4I  ft.),  so  that  the  pressure  of  the  fluid  will 
overcome  the  resistance  of  the  compressor  urethrae  muscle  and  flow 
into  the  posterior  urethra  and  thence  into  the  bladder. 


Fig.  127. — Keyes-Ultzmann  instillating  syringe. 

Instillations  erode  the  surface  of  the  urethra,  so  that  the  silver, 
and  also  the  zinc  or  permanganate  injections  used  subsequently, 
come  in  contact  with  the  diseased  structures  beneath.  Janet's  irriga- 
tions cause  the  tissues  to  swell  and  become  infiltrated  with  fluid. 
Both  procedures  also  bring  the  medicament  into  the  posterior 
urethra,  the  true  seat  of  infection,  and  it  is  to  these  facts  that  the 
excellent  results  obtained  with  either  method,  or  with  a  combination 
of  the  two,  are  to  be  attributed.  During  the  period  of  this  treat- 
ment the  patients  should  use  weak  astringent  injections,  such  as  zinc 
sulphate  or  lead  acetate  0.2:100  (1  grain  to  the  ounce). 

Much  more  difficult  are  those  cases  which  despite  the  employment 
of  this  treatment  do  not  get  well.  Such  cases  may  be  divided  into 
two  classes  according  to  the  cause  upon  which  they  depend. 

One  class  is  characterized  by  the  fact  that  the  symptoms,  whether 
they  be  discharge,  morning-drop,  gluing  of  the  meatus,  or  only  fila- 
ments in  the  urine,  remain  uninfluenced  by  any  treatment  whatsoever; 
in  the  second  class  the  symptoms  are  held  in  abeyance  as  long  as  treat- 
ment is  continued,  but  unfortunately  return  as  soon  as  it  is  stopped. 


120  DISEASES    OF    THE    URETHRA    AND    PENIS. 

The  first  are  almost  always  due  to  infiltrative  catarrh,  a  con- 
dition in  which  an  infiltrative  process  affects  the  walls  of  the  urethra  and 
constantly  causes  pus  cells  to  be  thrown  off  from  the  surface,  while  in 
the  second  the  glandular  sexual  organs,  especially  the  prostate,  are  the 
seat  of  an  inflammatory  catarrhal  process.  In  these  cases  it  is  imma- 
terial whether  gonococci  are  present  or  not,  for  the  existence  of  the 
catarrh  has  nothing  to  do  with  the  presence  or  absence  of  micro- 
organisms. 

In  urethral  catarrh  there  is  an  associated  prostatitis  in  85  per  cent  of 
all  cases,  a  fact  of  great  importance  as  regards  treatment.  The  diag- 
nosis of  prostatitis  can  be  made  solely  by  examining  the  prostatic 
secretion.  Not  a  single  subjective  symptom  may  be  present  and  yet  a 
catarrh  of  the  prostate  exist.  No  dependence  is  to  be  placed  upon  pal- 
pation, because  palpation  of  a  healthy  prostate  oftentimes  produces 
severe  pain  and  frequently  gives  rise  to  a  sense  of  faintness.  Palpable 
changes  can  only  occasionally  be  determined.  In  such  cases  the  gland 
may  be  found  enlarged  in  any  of  its  diameters,  or  it  may  present  cir- 
cumscribed swellings  and  prominences.  If  it  be  increased  in  thick- 
ness it  will  arch  toward  the  rectum.  When  examined  cystoscopically 
changes  may  or  may  not  be  perceptible.  Sometimes  the  border  of  the 
sphincter,  which  in  health  looks  perfectly  or  nearly  smooth  with  a 
slight  upward  concavity,  presents  a  serrated  or  dentated  appearance. 
It  is  obvious  that  this  picture  will  be  shown  only  when  that  part  of  the 
prostate  which  lies  near  the  urethra  or  bladder  is  affected. 

A  prostatitis  may  cause  subjective  disturbance,  which  consists  princi- 
pally of  a  sense  of  heaviness  in  the  rectum  with  pain  radiating  to  the 
anus  and  hips.  Sitting  is  often  uncomfortable.  Severe  exertion, 
especially  horseback  riding  and  bicycling,  increase  the  pain.  The 
bowels  are  constipated  and  evacuations  are  often  painful ;  occasionally 
the  prostatic  secretion  is  ejected  at  stool.  Sexual  power  is  usually 
diminished,  as  a  result  of  which  the  patients  easily  become  neurasthenic. 
All  these  symptoms,  however,  may  be  absent  and  yet  a  catarrh  of  the 
prostate  exist ;  the  urine  may  even  be  absolutely  clear,  so  that  there  is 
nothing  whatever  which  points  to  the  existence  of  prostatitis. 

The  sole  means  of  detecting  its  presence  is  by  examining  the 
prostatic  secretion,  which  in  normal  cases  is  seen  when  examined 
microscopically  to  consist  of  small  refractive  fat-globules,  resembling 
lecithin-bodies,  with  a  sprinkling  of  epithelia  and  a  few  white  cells. 
Now  and  then,  but  on  the  whole  very  rarely,  concentric  stratified 


TREATMENT    OP    URETHRITIS.  121 

corpuscles  and  a  few  red  cells  are  found,  which  result  from  massage 
of  the  gland. 

If  prostatitis  be  present  leucocytes  dominate  the  picture.  We  dis- 
tinguish three  degrees  of  inflammation :  in  the  first  there  are  only  a  few 
pus-cells — not  more  than  ten  or  twenty  in  the  entire  field;  in  the  second 
lecithin-corpuscles  are  outnumbered  by  pus-cells;  in  the  third  there  are 
very  few  if  any  lecithin-corpuscles,  pus-cells  filling  the  entire  field. 

To  obtain  the  prostatic  secretion  the  prostate  must  be  massaged, 
which  can  be  easily  done  through  the  rectum.  We  must  be  certain  that 
the  secretion  does  not  become  mixed  with  pus  in  its  passage  to  the  ex- 
ternal orifice  of  the  urethra,  and  thereby  lead  to  error  in  diagnosis.  If 
the  urine  is  clear  and  there  is  little  urethral  discharge,  the  patient  is  in- 
structed to  retain  his  water  until  the  bladder  becomes  full  and  then  is 
made  to  urinate  and  thereby  cleanse  his  urethra;  the  gland  is  then 
immediately  massaged. 

In  case  there  is  an  abundant  discharge  both  the  anterior  and  posterior 
urethra  must  be  irrigated  until  the  return  fluid  comes  away  clear  and 
free  from  nocculi.  In  acute  cases  this  would  be  impossible  because  pus 
would  collect  in  the  urethra  before  the  gland  could  be  massaged.  It  can 
be  done  very  well  in  chronic  cases,  to  which  we  now  have  reference. 

Sometimes  it  will  not  be  possible  to  force  the  secretion  out  of  the 
urethra,  as  it  will  flow  back  into  the  bladder.  The  examination  of  the 
usually  turbid  urine  passed  immediately  afterwards  can  not  be 
entirely  depended  upon,  but  it  is  so  rare  for  the  prostatic  secretion  to 
flow  back  that  the  occurrence  need  not  be  reckoned  with. 

The  treatment  of  these  cases  is  difficult  and  tedious.  As  long  as 
treatment  is  continued  they  appear  to  improve  or  to  get  well;  if  the 
treatment  is  stopped  the  symptoms — discharge,  gluing  of  the  meatus, 
filaments  in  the  urine — recur.  This  is  easily  explained  by  assuming 
that  the  urethral  catarrh  is  suppressed  by  the  irrigations  or  instillations, 
but  that  as  soon  as  they  are  stopped  the  morbid  process  affecting  the 
prostate  extends  to  the  urethra  by  way  of  the  excretory  ducts. 

I  have  not  been  able  to  convince  myself  of  the  efficacy  of  the  numerous 
remedies  recommended  for  gonorrhceal  prostatitis.  Great  value  has 
been  attributed  to  local  applications  of  iodine  or  ichthyol,  made  in  the 
form  of  suppositories  introduced  into  the  rectum.  Electrization  of 
the  gland  and  hot  irrigations  by  means  of  Arzberger's  apparatus  have 
also  been  highly  recommended.  All  these  procedures  are  good  inas- 
much as  they  relieve  the  subjective  symptoms  of  the  patients,  who  are 


122  DISEASES    OF    THE    URETHRA    AND    PENIS. 

frequently  of  a  nervous  type.  This  is  especially  true  of  the  hot-water 
irrigations.  Under  their  use  the  anal  pain  and  the  sense  of  com- 
pression and  rectal  tenesmus  become  less  or  temporarily  disappear, 
but  no  change  in  the  objective  symptoms  is  wrought.  The  composi- 
tion of  the  prostatic  secretion  is  not  altered;  it  remains  purulent  as 
before. 

Very  recently  cauterization  of  the  prostate  by  the  Bottini-Freudenberg 
method  has  been  tried.  In  two  cases  thus  treated  the  result  was  nega- 
tive;  moreover,  in  both  cases  the  neurasthenic  symptoms  were  intensified. 
Up  to  the  present  time  only  one  procedure  has  proved  both  efficacious 
and  harmless,  namely,  systematic  massage  of  the  prostate.  I  gen- 
erally have  it  done  thrice  weekly  by  a  masseur,  and  combine  with  it 
Janet's  irrigations  with  weak  potassium  permanganate  or  silver  nitrate 
solutions.  These  are  always  necessary,  for  the  urethra  is  almost 
invariably  affected.  They  should  be  used  twice  or  three  times  a  week 
and  in  the  intervals  •  between  their  employment  the  patient  may  be 
allowed  to  use  weak  injections  of  potassium  permanganate  or  zinc 
sulphate.  Under  this  treatment  the  discharge  disappears,  the  flocculi 
become  less  and,  what  is  of  more  importance,  the  pus-cells  in  the 
prostatic  secretion  considerably  diminished.  In  a  few  cases  it  is 
possible  to  cause  them  completely  to  disappear,  but  most  frequently  a 
few  permanently  remain;  from  this  condition,  however,  I  have  never 
observed  any  injurious  effect.  This  treatment  must  be  persevered  in 
for  months. 

Much  less  amenable  to  treatment  are  the  so-called  chronic  infiltra- 
tive forms  of  urethritis,  the  pathogenesis  of  which  we  have  already 
described.  They  are  characterized  by  the  obstinacy  with  which  they 
resist  all  our  therapeutic  efforts.  While  the  cases  complicated  with 
prostatitis  are  at  least  temporarily  benefited,  in  these  the  discharge,  the 
agglutination  of  the  meatus,  and  the  flocculi  remain  practically  unin- 
fluenced. The  infiltrative  process  frequently  remains  confined  to  the 
glands  and  crypts  in  which  it  originates,  although  it  may  extend  and 
involve  other  structures  of  the  urethra.  In  both  instances,  but  especially 
in  the  latter,  the  result  is  a  partial  rigidity  of  the  urethral  walls,  which  in 
the  worst  cases  leads  to  perceptible  narrowing  of  the  canal.  When  the 
walls  lose  their  elasticity  the  delicate  urethral  musculature  becomes  de- 
prived of  its  tonicity  and  allows  the  glands  to  dilate,  so  that  their  secre- 
tion instead  of  being  retained  flows  out  into  the  urethra,  from  which 
it  is  carried  awav  bv  the  urine  in  the  form  of  filaments. 


TREATMENT    OF    URETHRITIS.  1 23 

In  view  of  its  pathogenesis  it  has  long  been  the  custom  to  treat  infil- 
trative catarrh  by  a  combination  of  mechanical  and  chemical  methods, 
the  mechanical  being  used  for  the  purpose  of  removing  the  infiltrate, 
the  chemical  for  the  purpose  of  healing  the  accompanying  catarrh.  To 
obtain  this  end  Ultzmann  recommended  the  introduction  of  sounds  of 
increasing  size,  which  were  allowed  to  remain  in  the  urethra  for  some- 
time.    The  patient  also  used  injections. 

Unna,  wishing  to  combine  both  treatments  in  one,  smeared  the  sounds 
with  cocoa-butter  containing  2  per  cent  of  silver  nitrate.  The  heat  of 
the  body  dissolves  this  mixture  so  that  it  gains  access  to  the  glands  and 
crypts  opened  by  passage  of  the  sound.  Later,  in  order  to  render  this 
procedure  more  efficacious,  I  recommended  the  use  of  a  tunnelled 
sound  in  the  hollow  of  which  the  silver-lanoline  preparation  is  placed. 

[Better  than  either  of  these  devices  are  the  modern  ointment  applica- 
tors, such  as  Young's  and  Robbins'.     Young's  instrument  consists  of 


Fig.  128. — Robbins'  ointment  applicator. 

an  outer  tubular  sheath  of  a  little  more  than  half  a  circle  extent  and  a 
removable  solid  obturator  of  a  corresponding  size.  This  can  be  rotated 
in  the  outer  sheath  so  that  a  large  trough  to  be  filled  with  ointment  is 
furnished.  When  this  has  been  filled  the  rotation  is  continued  until  it 
furnishes  a  closed  round  instrument  with  the  ointment  inside.  In 
this  position  it  is  ready  for  insertion.  After  being  introduced  into 
the  urethra,  the  obturator  is  rotated  back  to  its  first  position  and  the 
ointment  is  thus  pushed  out  of  the  instrument  into  the  urethra.  The 
instrument  is  then  withdrawn,  the  operator  making  pressure  upon 
the  glans  and  the  meatus  to  prevent  the  escape  of  ointment. 

The  deep  urethral  applicator,  devised  by  Dr.  F.  W.  Robbins,  of 
Detroit,  Mich.  (Fig.  128.)  consists  of  a  hollow  catheter-like  metal 
tube,  a  cup  and  a  plunger.  The  tube  and  plunger  are  detachable 
from  the  cup.  The  cup  is  filled  with  ointment,  which  is  pressed 
down  with  a  spatula  so  as  to  obliterate  all  air  spaces,  the  plunger 
introduced  and  turned  slightly  around  until  the  ointment  appears 
at  the  end  of  the  urethral  tube,  and  the  tube  then  passed  into  the 
urethra.     While  turning  the  plunger  the  instrument  is  slowly  with- 


124 


DISEASES    OF    THE    URETHRA    AND    PEXIS. 


drawn  the  length  of  the  surface  to  be  medicated.  When  this  surface 
has  been  passed  over  the  escape  of  ointment  is  prevented  by  stopping 
the  movement  of  the  plunger  and  the  instrument  is  withdrawn  from 
the  urethra.* 

For  preparing  urethral  ointments  lanolin  is  a  better  base  than  cocoa 
butter  for  the  reason  that  it  has  the  power  of  taking  up  aqueous 
secretions.  I  am  of  the  opinion  too  that  it  adheres  better  to  the 
mucous  membrane  of  the  urethra  than  does  cocoa  butter.  The 
medicinal  substances  incorporated  in  the  ointments  must  be  made 
to  suit  the  pathological  condition  against  which  their  action  is 
directed.  For  periurethral  infiltrations  iodine  is  undoubtedly  the 
best.  For  cases  in  which  the  urethral  epithelium  has  been  changed 
from  its  normal  type  to  pavement  epithelium,  with  much  thickening 
and  rigidity  of  the  mucosa  and  constant  exfoliation  of  cells,  i  per 
cent  salicylic  acid,  as  recommended  by  Young,  will  often  prove 
serviceable.     For    hypersensitiveness,   cocaine,  carbolic    acid,  boric 


Fig.  129. — Oberlander's  dilators. 

acid,  zinc  oxide,  singly  or  in  various  combinations,  may  afford  relief. 
I  have  used  cocaine  gr.  iiss,  zinci  oxidi  3ss,  ungt.  acidi  borici  3nss> 
ol.  amygdalae  dulc.  f  3i,  lanolin,  ^iv,  with  excellent  results  in  these 
cases.  For  deep  urethral  applications,  silver  nitrate  and  iodine  are 
the  ones  most  frequently  indicated.] 

Then  came  the  era  of  dilators,  the  first  of  which  was  designed  by  Ober- 
lander.  As  the  urethral  orifice  will  not  permit  the  introduction 
of  large  instruments  he  constructed  an  instrument  which,  when 
closed,  is  about  the  size  of  a  16  F.  sound,  but  which  can  be  unscrewed 
and  the  branches  thus  separated  after  it  is  introduced  into  the  urethra. 

*The  short  tube  shown  in  the  illustration  may  be  used  for  rectal  applications. 
It  is  to  be  attached  to  the  cup  after  the  urethral  tube  is  unscrewed. 


TREATMENT    OF    URETHRITIS. 


I25 


Lohnstein,  Kollman  and  others  followed  with  four  and  eight  bladed 
dilators. 

From  my  own  experience  I  believe  mechanical  treatment,  com- 


Fig.  130 — Kollmann's  dilators. 

bined  with  local  medicinal  measures  to  be  good  and  useful  if  prac- 
tised with  great  caution  and  within  wise  limits.  All  measures  which 
lacerate  the  urethra  are  evil;  they  add  new  scars  to  the  old  process.  At 
first  sounds  as  large  as  the  urethra  will  admit  are  passed  twice  a  week. 


126  DISEASES    OF    THE    URETHRA    AND    PENIS. 

In  the  intervals  the  patient  uses  injections  or  receives  irrigations. 
When  23  or  24  F.  is  reached  dilators  are  used,  and  of  these  I  prefer 
the  excellent  instrument  of  Oberlander  (Fig.  129).  [Kollmann's  four- 
bladed  dilators  are  also  admirable  instruments.  (Fig.  130.)]  Dilata- 
tion should  not  be  practised  oftener  than  once  or  twice  a  week  and 
the  urethra  should  be  stretched  very  gradually,  an  increase  of  not 
more  than  1  mm.  being  made  at  each  sitting. 

I  have  tested  the  method  of  simultaneous  dilatation  and  irrigation  and 
see  no  advantage  in  it.  Perhaps  local  urethrotomy  may  lead  us  further. 
It  is  performed  with  an  instrument  constructed  after  the  principle  of 
Otis  and  slightly  modified  by  Kreisl  (Fig.  131).  With  it  one  or  more 
incisions  are  made  at  the  site  of  infiltration.  I  believe  that  this  pro- 
cedure is  quicker  and  surer  than  dilatation. 


^mm 


Fig.  131. — Otis-Rreisl  urethrotome. 

[Urethroscopic  examination  may  show  that  slight  chronic  dis- 
charge or  filaments  in  the  urine  are  due  to  chronically  inflamed 
urethral  glands,  superficial  granulations  which  have  failed  to  yield 
to  dilatation,  or  papillomata. 

Diseased  glands  may  be  destroyed  by  means  of  Kollmann's  or 
Oberlander's  electrolytic  needles,  or  split  open  with  Kollmann's  or 
Bierhoff's  knife. 

t  These  instruments  are  used  through  the  urethroscope  under  direct 
guidance  of  the  eye.  Kollmann's  needle  is  connected  to  the  negative 
pole  of  a  battery  supplying  the  constant  current  and  a  flat  electrode 
is  attached  to  the  positive  pole.  The  flat  electrode  is  placed  on  the 
thigh,  the  needle  is  passed  through  the  urethroscope  and  its  point 
inserted  into  the  opening  of  the  diseased  gland.  From  three  to  five 
milliamperes  of  the  current  are  now  turned  on  and  the  needle  left  in 
situ  for  one  or  two  minutes. 

Oberlander's  double  needle  may  be  used  in  this  way,  or  one  needle 
may  be  attached  to  the  positive  pole  and  the  other  to  the  negative. 


TREATMENT    OF    URETHRITIS.  1 27 

The  current  should  always  be  turned  off  before  the  instrument  is 
withdrawn  from  the  urethra.  Not  more  than  two  or  three  glands 
should  be  destroyed  at  one  sitting. 

From  observations  made  in  Wossidlo's  clinic,  Mundorff  states  that 
the  delicate  scars  resulting  from  this  procedure  may  develop  into 
true  strictures  if  too  strong  a  current  be  used.  Therefore,  it  is 
important  that  only  a  weak  current,  as  above  recommended,  be 
employed.  Mundorff  advises  the  use  of  large  steel  sounds  during 
the  process  of  healing. 

The  urethral  knife  serves  not  only  to  split  open  diseased  glands, 

but  also  to  divide  infiltrations  and  delicate  bands  of  cicatricial  tissue. 

Granulations  may  be  touched  with  silver  nitrate  or  copper  sulphate. 

A  solution  containing  sixty  grains  to  the  fluid  ounce  of  distilled  water 

may  be  used. 

Papillomata  may  be  snared,  or  torn  off  with  urethral  forceps,  and 
their  base  touched  with  the  galvano-caustic  needle  or  trichloracetic 
acid,  preferably  the  former,  for  the  reason  that  the  acid  diffuses  itself 
over  surrounding  healthy  tissue  unless  great  care  be  employed  in 
applying  it.] 

The  results  attained  in  infiltrative  urethritis  are  very  moderate  as 
regards  cure.  That  such  must  be  the  case  is  self-evident.  Until  we 
are  able  to  remove  the  rigidity  of  the  urethra  we  cannot  expect  to 
arrest  a  discharge  which  depends  upon  this  rigidity. 

This  leads  to  the  important  question  as  to  what  we  shall  do  with 
those  patients  in  whom  we  fail  to  suppress  the  discharge,  that  is  to  say, 
those  in  whom  a  slight  secretion  persists  either  in  form  of  a  drop  at  the 
meatus  or  as  filaments  in  the  urine. 

According  to  my  experience  the  whole  situation  depends  solely 
upon  whether  a  given  case  is  considered  infectious,  and  by  infectious 
we  mean  only  those  in  which  the  gonococcus  has  been  found  or  those 
which  are  known  to  have  conveyed  infection  to  the  female. 

In  regard  to  the  gonococcus  it  has  already  been  stated  that  its  isolation 
sometimes  presents  great  difficulties,  and  that  for  this  reason  the  decision 
as  to  whether  a  case  is  infectious  or  not  may  be  most  difficult.  It  has 
been  observed  that  the  filaments  present  in  the  urine  may  contain  no 
gonococci  and  yet  these  bacteria  be  present  in  the  secretion  obtained 
with  the  bulbous  bougie.  Authentic  cases  are  met  with  often  enough 
in  which  a  healthy  man  contracts  gonorrhoea  from  a  woman  in  whom 
not  the  slightest  evidences  of  disease  are  manifest ;  conversely,  women 


120  DISEASES    OF    THE    URETHRA    AND    PENIS. 

whose  husbands  show  no  recognizable  symptoms  may  develop  the 
disease.  Furthermore  there  are  cases  in  which  the  urethral  secretion 
is  free  from  gonococci  although  these  bacteria  are  present  in  the  prostatic 
secretion;  the  reverse  is  also  true.  We  have  already  mentioned  those 
cases  in  which  the  gonococci  remain  latent  for  months  and  then 
suddenly  reappear  in  the  secretion. 

These  conditions  enormously  increase  the  difficulty  of  deciding  as  to 
whether  a  case  is  infectious,  and  mistakes  doubtless  occur.  Notwith- 
standing this,  experience  has  supplied  us  with  certain  data  which  help  us 
in  passing  judgment.  Thus,  cases  in  which  gonococci  are  lurking  are 
characterized  by  variations  in  the  quantity  of  discharge,  whereas  in 
those  free  from  gonococci  the  discharge  is  fairly  constant  in  quantity, 
although  it  resists  every  therapeutic  measure. 

We  must  see  to  it  that  such  cases  remain  under  observation  a  long  time 
so  that  they  can  be  frequently  examined.  If  the  secretion  obtained  by 
stripping  the  urethra,  massaging  the  prostate,  and  probing  with  the 
bougie  a.  boule  has  been  found  free  from  gonococci  after  repeated  exam- 
ination, and  if  they  do  hot  appear  after  the  urethra  has  been  subjected  to 
different  forms  of  irritation,  then  we  may  discharge  the  patient  from 
treatment  and  also  give  our  consent  to  his  marriage.  In  my  opinion  it 
is  not  necessary  to  treat  the  patients  as  long  as  pus-cells  continue  to  be 
found  in  the  filaments  or  in  the  discharge.  The  shreds  often  remain 
permanently.     We  have  already  said :  "  Of  two  evils  choose  the  lesser. " 

The  greater  evil  is  to  subject  men  thus  affected  to  a  protracted  course 
of  treatment  which  frequently  not  only  fails  to  suppress  the  secretion, 
but,  moreover,  changes  a  mild  type  of  neurasthenia  into  a  severe  one. 

Herein  lies  the  difficulty  of  the  whole  matter.  What  a  large  number  of 
men  suffering  with  cerebrasthenia,  myelasthenia,  impotence,  hypochon- 
dria, melancholia  and  kindred  affections  come  to  us  year  in  and  year 
out !  These  people,  who  unfortunately  are  often  honorable  and  estim- 
able members  of  society,  have  been  reduced  to  their  wretched  condition 
by  a  "clap  which  would  not  heal;"  the  more  conscientious  they  are  and 
the  more  they  lose  faith  in  the  curability  of  their  urethral  catarrh,  the 
more  certain  are  they  to  become  the  victims  of  sexual  neurasthenia. 
When  they  go  from  one  doctor  to  another  and  take  from  each  a  fruitless, 
protracted,  and  usually  painful  course  of  treatment,  and  are  forbidden 
by  each  to  marry,  the  predisposition  to  neurasthenia  is  enhanced. 

Although  excessive  treatment  is  harmful  the  patient  must  not  be 
denied  necessary  attention.     It  is  self-evident  that  the  urethritis  should 


CHANCROID    OF    THE    URETHRA.  120, 

be  cured  if  possible.  The  experienced  and  judicious  physician  will  be 
able  to  tell  within  a  short  time  what  he  can  accomplish  in  a  given  case. 
If  he  decides  that  the  case  cannot  be  cured  in  the  ideal  sense  of  the  term, 
then  it  becomes  his  duty  to  assure  the  patient  of  the  harmlessness  of  his 
condition,  of  the  triviality  of  his  affection. 

It  is  generally  known  that  this  is  no  easy  task.  Gonorrhophobiacs 
want  to  be  treated  under  all  circumstances,  even  though  treatment  is 
painful.  They  do  not  trust  a  physician  who  assures  them  that  the  fila- 
ments in  their  urine  are  of  no  significance.  In  spite  of  this  it  must  be 
our  aim  to  convince  them  that  what  seems  to  them  to  be  disease  is  in 
reality  no  longer  disease,  but  merely  its  sequel.  Do  not  deny  these  per- 
sons help.  They  need  medical  advice.  A  general  hygienic  regimen 
should  be  prescribed  for  them.  Baths  constitute  an  important  part  of 
such  a  regimen,  but  it  is  not  necessary  for  me  to  describe  them  in  detail 
as  they  are  known  to  every  well-informed  physician. 

If  we  follow  this  course  we  shall  save  from  neurasthenia  many  so- 
called  gonorrhceal  patients  who  in  reality  are  not  gonorrhceal,  and  shall 
also  be  able  to  restore  to  health  and  strength  many  neurasthenics  whose 
disease  depends  upon  gonorrhophobia. 

CHANCROID  OF  THE  URETHRA. 

Soft  chancres  of  the  urethra  are  of  relatively  uncommon  occurrence. 
They  are  located  in  the  anterior  part  of  the  urethra,  seldom  being 
further  back  than  the  termination  of  the  glans.  They  cause  pain- 
ful micturition  and  a  profuse  purulent  discharge,  which  differs  from 
gonorrhceal  discharge  in  that  it  contains  no  gonococci  and  is  little 
influenced  by  the  ordinary  injections  used  for  clap.  The  presence  of 
associated  sores  on  the  penis  or  edge  of  the  meatus,  and  finally  the 
the  use  of  the  endoscope,  facilitates  diagnosis.  From  hard  sores  they 
are  differentiated  by  abscence  of  induration  and  cedematous  swelling; 
the  short  period  of  incubation  has  also  some  bearing  on  the  case. 

Hard  chancres  heal  without  scar- formation  and  therefore  produce  no . 
strictures;  extensive  soft  sores   may  lead  to  stenosis. 

As  to  treatment  the  introduction  of  urethral  cylinders  composed  of 
cocoa  butter  and  iodoform  is  to  be  recommended.  The  patient  urinates 
and  then  a  cylinder  is  passed  into  the  urethra  as  deep  as  it  will  go 
without  producing  pain.  The  meatus  is  then  covered  with  a  pledget  of 
cotton  or  gauze,  so  that  the  iodoform  can  remain  in  the  urethra  for  some- 
time. Under  this  treatment  cure  is  rapid. 
9 


130  DISEASES    OF    THE    URETHRA    AND    PENIS. 

ACUMINATED  CONDYLOMATA  OF  THE  URETHRA. 

These  growths  may  occur  either  in  association  with  or  independently 
of  others  on  the  external  parts.  They  are  generally  near  the  external 
orifice,  but  are  also  encountered  in  the  posterior  urethra.  They  do  not 
differ  in  any  respect  from  those  found  on  the  external  structures.  Usu- 
ally they  appear  as  small  isolated  warts  within  the  urethra;  it  is  very 
rare  for  them  to  grow  large  enough  to  cause  obstruction. 

They  generally,  .though  not  always,  follow  gonorrhoea;  they  may 
develop  in  the  urethra  just  as  they  do  on  the  skin  of  persons  who 
have  never  had  the  disease. 

The  symptoms  of  urethral  condylomata  are  very  slight.     They  consist 

of  slight  burning,  scanty  discharge  which  does  not  yield  to  injections 

i  and  which  therefore  may  simulate  chronic  gonorrhoea,  and  occasionally 

trifling  haemorrhage  from  the  urethra,  or  the  passage  of  blood-tinged 

urine.     With  the  endoscope  they  can  be  brought  plainly  into  view. 

Treatment  requires  their  removal,  because  if  left  they  may  grow  and 
produce  symptoms  of  stricture,  or  apparently  keep  up  a  gonorrhoea. 
Those  situated  near  the  urethral  orifice  can  be  made  accessible  by  everting 
the  meatus,  and  can  then  be  cut  off  and  their  base  cauterized  with  nitrate 
of  silver  or  trichloracetic  acid.  Those  situated  further  back  may  be 
reached  through  the  cystoscope,  if  practicable,  and  cauterized.  Often 
it  will  suffice  to  pass  large  bougies  which  tear  them  from  their  base. 

SYPHILIS  OF  THE  URETHRA. 

Syphilis  may  affect  the  urethra  in  three  ways:  first  as  the  initial 
lesion,  the  hard  chancre;  second  as  a  symptom  of  secondary  syphilis; 
third  as  a  gumma. 

The  most  common  of  the  three  is  the  hard  chancre,  which  has  been 
observed  as  far  back  as  the  coronary  sulcus.  A  hard  nodule,  which 
eventually  becomes  merely  a  firm  indurated  mass,  is  felt  from  without, 
although  there  are  no  signs  of  disease  on  the  penis. 

The  urethra  is  cedematous  and  the  lips  of  the  meatus  are  swollen,  a 
condition  which  produces  the  symptoms  of  stricture.  The  sore  causes 
no  special  symptoms;  it  simulates  gonorrhoea,  only  the  discharge  is  not 
so  thick,  purulent  and  creamy,  but  sero-purulent  or  sero-sanguinolent 
and  does  not  contain  gonococci.  The  urethra  is  so  swollen  and  cedema- 
tous that  it  is  impossible  to  introduce  a  tube  sufficiently  large  to  enable 


STRICTURE    OF    THE    URETHRA.  131 

anything  positive  to  be  determined.  Moreover,  the  introduction  of 
instruments  is  contraindicated  because  it  may  beget  lymphangitis. 

In  reference  to  diagnosis,  the  condition  may  be  confounded  with 
thick  periurethral  infiltrates,  although  these  are  scarcely  if  ever  so 
large  as  the  nodules  of  syphilis;  the  short  period  of  development- 
infiltrates  require  a  longer  time — the  ineffectiveness  of  antigonorrhceal 
therapy,  the  associated  indolent  buboes,  and  the  appearence  of  other 
symptoms  of  syhpilis  all  serve  to  confirm  the  diagnosis. 

Secondary  syphilitic  affections  of  the  urethra  consist  of  exanthe- 
mata such  as  occur  on  other  mucous  membranes.  They  occur  very 
seldom  and  are  much  more  seldom  detected.  They  progress  under 
the  guise  of  gonorrhoea,  from  which  they  can  be  distinguished  only 
by  the  absence  of  gonococci,  the  inefficacy  of  antigonorrhceal  therapy, 
and  the  use  of  the  endoscope. 

Gummata  of  the  urethra  are  seen  more  frequently,  occurring  in  the 
form  of  circumscribed  nodules  before  disintegration  occurs  and  as 
ulcers  after  disintegration  has  taken  place.  Their  recognition  is  of 
great  importance,  because  if  not  interfered  with  they  may  produce  con- 
siderable disturbance.  Many  urethral  fistulae  near  the  meatus  owe 
their  origin  to  an  unrecognized  gumma.  A  thorough  examination, 
above  all  things  a  careful  anamnesis,  the  presence  of  other  late  mani- 
festations of  syphilis,  and  the  fruitlessness  of  the  usual  treatment 
make  the  diagnosis  not  difficult. 

As  to  treatment  it  may  be  said  that  these  secondary  syphilitic  affec- 
tions of  the  urethra  do  not  demand  any  local  measures;  they  get  well 
under  general  treatment.  In  hard  chancre  Unna's  gray  plaster  may  be 
applied  to  the  penis  over  the  site  of  the  internal  sore  and  a  general 
mercurial  treatment  instituted,  whereupon  the  ulcers  will  rapidly 
heal.  For  gummata  large  doses  of  the  iodides  are  required,  5,  10,  or 
even  15  Grm.  (from  75  to  225  grains)  a  day  being  given.  The  result 
is  surprising. 

STRICTURE  OF  THE  URETHRA. 

Conception  of  stricture.  If  we  bear  in  mind  the  so  often  forgotten 
fact  that  the  urethra  when  at  rest  is  a  closed  canal  the  walls  of  which 
are  in  direct  contact,  there  can  hardly  be  a  better  definition  of  stricture 
than  the  one  given  by  Sir  Charles  Bell,  who  described  it  as  a  condition 
in  which  the  affected  portion  of  the  urethra  has  lost  its  dilatability. 
The  acceptance  of  this  definition   excludes   two    conditions  which, 


I32  DISEASES    OF    THE    URETHRA    AND    PENIS. 

though  generally  classified  as  strictures,  are  not  such  in  reality ;  namely, 
spastic  and  inflammatory  obstruction. 

The  urethra  can  doubtless  be  contracted  or  entirely  occluded  at 
any  part  of  its  course  by  spasm  or  inflammation,  as  for  example,  by 
the  cedematous  swelling  of  acute  gonorrhoea;  these,  however  are  only 
transitory  phenomena,  the  urethral  walls  still  retaining  their  elasticity. 
As  soon  as  the  spasm  or  the  inflammation  has  been  subdued  by  anti- 
spasmodic or  antiphlogistic  treatment  they  reassume  their  normal  exten- 
sibility. These  conditions,  therefore,  may  be  considered  as  spasmodic 
and  inflammatory  obstructions,  as  occlusions  and  the  like,  but  not  as 
strictures.  In  contradistinction  to  them  true  strictures  present  a  per- 
manent narrowing  caused  by  plastic  changes  in  the  urethral  walls. 
Tumors  (epithelioma,  sarcoma,  fibro- sarcoma)  and  tubercles  which 
grow  from  the  wall  of  the  urethra,  infiltrating  it  and  also  sometimes 
projecting  so  as  partly  or  entirely  to  occlude  its  lumen,  are  not  classed 
as  strictures. 

ETIOLOGY. 

If  we  exclude  congenital  strictures,  which  will  be  discussed  under 
malformations  of  the  urethra,  we  recognize  only  two  causes  for  the 
development  of  organic  stricture:  first,  inflammation  of  the  urethra, 
or  in  other  words  gonorrhoea;  and  second,  loss  of  substance  in  the 
urethra  due  to  either  trauma  or  ulceration. 

The  vast  majority  of  all  strictures  are  due  to  the  first  cause,  more 
than  go  per  cent  being  of  gonorrhceal  origin.  Simple  urethritis  hardly 
ever  leads  to  stricture  formation. 

All  strictures  which  result  from  loss  of  substance  and  consequent 
production  of  scar-tissue  during  the  process  of  healing  are  to  be  con- 
sidered as  traumatic.  The  trauma  may  consist  of  a  blow  or  wound 
from  without,  of  a  tear  during  coitus,  injury  due  to  introduction  of 
instruments,  or  to  passage  of  a  calculus  through  the  urethra.  Cauteri- 
zation, as  for  example,  that  due  to  injections  of  corrosive  fluids  such  as 
carbolic  acid,  and  destruction  due  to  a  wide-spreading  chancroid 
belong  in  the  same  category. 

In  my  opinion  syphilitic  strictures  do  not  exist.  Hard  sores,  which 
seldom  affect  the  urethra,  heal  without  a  scar,  and  urethral  gummata 
produce  only  a  transitory  obstruction;  after  proper  constitutional  treat- 
ment is  instituted  the  urethra  becomes  pervious. 


PATHOLOGICAL    ANATOMY    OF    STRICTURE.  1 33 

PATHOLOGICAL    ANATOMY. 

The  origin  of  urethral  stricture  will  be  understood  if  the  origin  of 
the  primary  causative  disease,  gonorrhoea,  be  borne  in  mind. 

As  in  all  inflammatory  processes  there  is  in  the  beginning  a  small- 
celled  infiltration  of  the  affected  part  resulting  either  from  emigration 
of  leucocytes  or  from  proliferation  of  connective-tissue  cells.  The 
chronicity  of  the  process  by  which  strictures  are  formed  speaks  rather 
in  favor  of  connective  tissue  proliferation,  although  as  a  matter  of  fact 
the  question  as  to  the  origin  of  the  primordial  round  cells  has  no  bear- 
ing on  the  further  course  of  the  morbid  process. 

As  more  and  more  intercellular  substance  becomes  interposed 
between  these  cells  they  become  separated  from  one  another  and  at 
the  same  time  change  their  form.  At  first  round,  they  later  give  off 
processes  and  thereby  become  changed  into  spindle  or  star-shaped 
bodies.  During  these  changes  in  the  cells  it  is  observed  that  the  inter- 
cellular substance  is  split  into  the  finest  and  most  delicate  fibers  and 
fibrils;  in  short,  true  connective  tissue  develops,  a  so-called  scar  being 
formed. 

If  the  process  continues  more  connective  tissue  develops  from  the 
newly  proliferated  or  extravasated  round  cells,  so  that  a  well  formed 
tumor,  or  callus,  results.  This  recently  formed  connective  or  scar- 
tissue  possesses  a  tendency  to  contract,  to  shorten,  to  shrink;  accord- 
ingly the  vessels  contained  within  it  suffer,  and  as  a  result  of  the  ensu- 
ing impairment  of  nutrition  it  gradually  becomes  paler  and  paler, 
eventually  causing  the  white,  tendinous  striae  often  found  in  callous 
stricture-tissue.  The  fact  of  greatest  importance,  however,  is  that  the 
tendency  of  the  callous  mass  to  contract  and  shrink  leads  to  dis- 
tortion, narrowing,  and  even  complete  occlusion  of  the  urethra. 

Loss  of  urethral  tissue,  likewise,  be  it  occasioned  by  trauma  or  by 
ulceration,  can  only  be  replaced  by  scar-tissue  having  a  tendency  to 
contract. 

The  individual  stages  of  chronic  gonorrhoea  and  their  transition  to 
stricture  are  well  shown  by  the  microscope.  In  comparatively  recent 
cases  the  subepithelial  layer  of  the  urethral  mucosa  is  seen  to  be 
thickly  and  evenly  infiltrated  with  leucocytes  throughout  a  wide  extent. 
Some  of  the  glands  are  considerably  dilated  and  certain  parts  of 
the  periglandular  tissue  show  a  moderately  thick  infiltration  of 
leucocytes.     In  cases  further  advanced  the  transformation  of  inflam- 


134  DISEASES    OF    THE    URETHRA    AND    PENIS. 

matory  product  into  scar-tissue  is  plainly  recognizable.  Although 
the  center  of  this  diseased  area  is  already  made  up  of  scar-tissue,  its 
borders  consist  of  young  granulation  tissue  rich  in  round  cells.  The 
epithelium  of  the  mucosa  undergoes  variable  degrees  of  thickening 
and  may  become  partly  cornified.  Since  the  uppermost  cells  of  this 
necrotic  epithelial  layer  exfoliate  and  become  mixed  with  the  mucous 
secretion  of  the  glands,  that  discharge  so  characteristic  of  chronic 
gonorrhoea  or  gleet  is  produced. 

During  the  further  progress  of  the  disease  the  glands  become  more 
or  less  destroyed.  The  desquamated  epithelium  is  too  dry  to  assume 
the  form  of  a  discharge,  so  the  latter  drys  up,  and  in  its  place  filaments 
composed  partly  of  round  cells  and  partly  of  epithelium  are  washed  out 
by  the  urine,  in  which  they  are  easily  found.  Thus  the  morbid  process 
may  exist  for  years  and  pursue  its  further  course  unnoticed.  The 
small-celled  infiltration  also  affects  the  deeper  parts,  in  which  it  likewise 
becomes  changed  into  a  layer  of  connective  tissue.  The  corpora 
cavernosa,  the  overlying  muscles,  and  the  erectile  tissue  of  the  penis 
may  all  be  converted  into  a  firm,  dense  scar;  thus  the  urethral  walls 
slowly  become  rigid,  unyielding,  and  in  the  most  advanced  cases  so 
closely  apposed  to  one  another  that  a  hair  can  scarcely  be  passed 
through. 

It  is  seen,  therefore,  that  the  specific  cause  of  gonorrhoea  has 
nothing  to  do  with  the  development  of  stricture  except  that  strict- 
ures of  gonorrhceal  origin  show  a  tendency  to  invade  the  deep  layers 
of  the  urethra,  whereas  those  due  to  simple  urethritis  confine  them- 
selves more  to  the  superficial  layers;  however,  a  simple  traumatic 
urethritis  or  one  due  to  any  other  cause  may  result  in  stricture  if  the 
inflammatory  infiltrate  advances  deeper  into  the  urethral  walls. 

On  the  other  hand,  this  hyperplastic  connective-tissue  formation  may 
not  only  infiltrate  the  walls  of  the  urethra,  but  may  also  grow  out- 
wards into  its  lumen.  Such  free  connective-tissue  tumors  lead  to  the 
development  of  firmly  adherent  stratifications,  as  the  result  of  which 
valves  and  funicles  are  formed  (valvular  stricture). 

Many  chronic  gonorrhoeas,  then,  represent  the  early  stage  of  stricture, 
or  may  even  be  considered  as  strictures  themselves,  being  the  so-called 
strictures  of  large  caliber  described  by  Otis.  When  a  certain  part  of 
the  urethra  is  infiltrated  with  round  cells  which  have  become  partly 
converted  into  connective  tissue  or  are  in  the  process  of  undergoing 
such  an  alteration,  great  rigidity  of  the  affected  area  is  produced. 


PATHOLOGICAL    ANATOMY    OF    STRICTURE.  I35 

This  portion,  although  still  more  or  less  dilatable,  will  offer  greater 
resistance  to  the  impingement  of  the  urinary  stream  than  the  other 
parts  of  the  urethra.  The  narrowing  may  be  very  slight,  perhaps  so 
slight  that  a  16  F.  sound  can  easily  be  passed  through  it.  In  such 
cases  the  so-called  stricture  of  large  caliber  exists  even  though  it  may 
not  be  noticed. 

The  evolution  of  stricture  does  not  always  terminate  in  the  way  above 
described,  for  the  firm,  callous  masses  occasionally,  though  rarely, 
undergo  still  further  transformation.  Just  as  bony  callus  can  undergo 
involution,  so  likewise  can  the  connective  tissue  masses  from  which, 
stricture  is  developed  pass  through  a  process  of  retrograde  metamor^ 
phosis. 

It  happens,  as  Dittel  has  said,  that  the  greater  part  of  the  em- 
bryonal connective  tissue  in  the  callus  becomes  resorbed,  so  that  a 
perfectly  shrunken  and  dryer  connective  tissue  remains.  In  callous 
strictures  the  urethra  feels  thick  and  cartilaginous,  but  in  this  form 
it  is  hard,  inelastic,  and  much  thinner  than  in  health  (scar-stricture, 
or  atrophied  stricture). 

To  this  class  belong  strictures  produced  by  ulceration  and  injury. 
The  degree  of  narrowing  and  the  amount  of  dilatability  depend  upon 
the  amount  of  substance  lost  and  upon  the  direction  which  the  injury 
takes.  Small  superficial  ulcerations  which  do  not  go  beyond  the 
mucous  membrane  make  only  a  minimum  of  narrowing.  The  deeper 
the  scar  goes  the  more  it  distorts  the  urethra.  If  laceration  due  to 
injury  extends  in  the  long  axis  of  the  canal  so  that  a  longitudinal  scar 
results,  the  contraction  will  be  much  slighter  than  if  it  occurs  in  the 
transverse  diameter  or  in  a  zigzag  direction.  Phagedenic  chancres 
situated  near  the  meatus  may  cause  great  destruction,  as  a  result  of 
which  very  narrow  and  unyielding  strictures  develop. 

The  macroscopic  appearance  of  strictures  varies  according  as  they 
are  of  the  callous  or  cicatricial  variety.  In  the  first  form  often  nothing 
is  seen  but  an  irregular  scar,  the  surface  of  which  lacks  the  luster  of 
the  normal  mucous  membrane,  the  scar  itself  being  firmly  adherent 
to  the  deeper  layers  of  the  urethra.  The  lumen  is  perceptibly 
narrowed. 

The  surface  of  callous  strictures  also  lacks  the  velvety  appearance  of 
normal  mucous  membrane.  The  latter  is  still  visible  at  certain  places, 
but  in  the  main  it  is  replaced  by  a  dull  white,  parchment-like  tissue: 
which  is  smooth  on  its  free  surface.     The  mucous  membrane  is  thick- 


i36 


DISEASES    OF    THE    URETHRA    AND    PENIS. 


ened,  hard,  and  adherent  to  the  erectile  tissue,  forming  a  scar  which  is 
more  or  less  bloodless. 

The  parts  behind  the  stricture  arc  generally  dilated;  in  slight  cases 
they  show  merely  a  little  chronic  inflammation,  but  in  severe  ones 
enormous  pouches  with  fibrillation  and  destruction  of  tissue  are  present, 
producing  a  condition  which  presents  the'  appearance  of  a  net- work. 
(Fig.  132). 

The  site  of  the  stricture  is  generally  in  the  penile  portion,  being 
"most  common  at  the  bulb,  where  it  becomes  continuous  with  the  mem- 
branous part.  Next  the  region  of  the  cutaneous  orifice  is  the  seat  of 
predilection,  while  the  third  rank  is  held  by  the  entire  anterior  urethra. 


>■=! 


< 


Fig.  132. — Net-work  of  tissue 
behind  a  stricture. 


a  b  f 

Fig.  133. — Different  forms  of  stricture. 


Strictures  originating  from  chancres  are  usually  located  near  the 
meatus,  and  gonorrhoeal  strictures  are  generally  in  the  region  of  the 
bulb.  The  latter  variety,  however,  are  for  the  most  part  mul- 
tiple, so  that  in  addition  to  those  at  the  bulb,  which  are  generally  the 
narrowest,  others  are  found  further  forward  in  the  urethra.  Gon- 
orrhoeal strictures  are  never  situated  beyond  the  membranous 
urethra.  Traumatic  strictures  may  occur  anywhere  in  the  urethra, 
but  generally  are  at  the  bulb  or  in  the  membranous  or  protatics 
portion. 

The  form  of  strictures  is  very  different.     Oftentimes  the  diminution 


SYMPTOMS    OF    STRICTURE.  137 

in  caliber  occurs  equally  from  all  sides  (Fig.  133  b).  It  may,  however, 
be  very  irregular,  so  that  the  opening  of  the  stricture  lies  eccentric  (a) ; 
indeed,  the  urethra  may  be  so  distorted  by  a  callus  of  irregular 
growth  as  to  present  a  zigzag  appearance,  a  condition  known  as  sprial 
stricture  (c). 

Likewise  the  length  of  strictures  varies  within  certain  limits.  They 
seldom  exceed  5  mm.  [about  \  of  an  inch],  but  occasionally  several 
lie  so  close  to  one  another  that  they  give  the  impression  of  a  single  long 
stricture. 

The  lumen  of  the  urethra  is  often  little  diminished,  although  it 
frequently  is  reduced  to  the  smallest  numbers  of  the  French  scale, 
and  in  extreme  degrees  of  contraction  no  opening  at  all  can  be  found. 

SYMPTOMS,    DIAGNOSIS   AND    PROGNOSIS. 

In  general,  strictures  produce  very  slight  disturbance,  so  that  in 
persons  who  take  little  care  of  themselves  they  are  not  usually  noticed 
until  they  are  very  far  advanced  in  their  development.  Careful,  intelli- 
gent men  observe  that  it  takes  them  longer  to  urinate  than  it  should. 
This  fact  is  explained  by  physical  laws.  It  takes  longer  for  a  definite 
quantity  of  urine  to  flow  through  a  narrow  tube  than  through  a 
wide  one. 

The  time  required  to  start  the  stream  of  urine  is  in  many  cases  not 
longer  than  that  taken  by  healthy  men.  The  frequency  of  urination, 
too,  may  be  entirely  normal.  It  is  only  when  the  stricture  is  very 
narrow  and  the  patient  does  not  completely  empty  his  bladder  that 
micturition  becomes  frequent.  '  Under  these  conditions  it  is  self- 
evident  that  the  bladder  will  become  filled  with  that  quantity  of  urine 
necessary  to  cause  micturition  in  a  shorter  time  than  under  normal 
circumstances.  This  incomplete  retention,  however,  is  absent  in  cases 
in  which  the  bladder  is  strong  and  the  stricture  not  very  narrow. 

Pain  may  also  be  entirely  absent,  but  usually  the  patient  complains 
of  a  slight  burning  upon  urinating,  which  is  experienced  the  moment 
the  urine  impinges  upon  the  contracted  spot.  The  site  of  the  stricture, 
then,  is  also  the  site  of  the  pain. 

Only  in  extreme  degrees  of  stricture  is  micturition  really  painful.  In 
such  cases  the  patients  are  obliged  to  strain  violently  in  order  to  force  out 
the  urine ;  they  bend  forward  so  as  to  secure  the  aid  of  abdominal  pres- 
sure, and  occasionally  employ  so  much  force  that  the  rectum  prolapses 
or  cerebral  haemorrhages  take  place. 


138  DISEASES    OF    THE    URETHRA    AND    PENIS. 

The  most  striking  deviation  from  the  normal  is  shown  by  the  urinary 
stream.  The  narrower  the  stricture  and  the  more  anterior  its  location 
the  greater  the  loss  of  volume  in  the  stream.  It  becomes  thinner 
and  thinner  until  it  is  reduced  to  the  size  of  a  thread,  and  then  finally 
becomes  obliterated  altogether,  the  urine  being  voided  only  drop  by  drop. 
The  projectile  power  of  the  stream  may  not  be  lessened;  although  small, 
it  can  often  be  cast  some  distance  forward.  In  extreme  degrees  of 
narrowing  this  power  is  also  lost. 

In  such  cases  ejaculation  of  semen  is  likewise  attended  with  difficulty. 
The  fluid  is  not  ejected  forcibly  outward,  but  flows  along  slowly,  or  is 
regurgitated  into  the  bladder. 

Incontinence  of  urine,  or  more  properly  speaking,  overflow  of  urine 
from  the  bladder,  is  one  of  the  most  common  occurrences  during  this 
stage  of  the  disease.  Behind  the  stricture  the  urethra  is  dilated  into  a 
funnel-shaped  expansion,  so  that  the  internal  vesical  sphincter  becomes 
stretched.  The  bladder  is  in  a  condition  of  incomplete  retention.  The 
urine  which  rises  above  the  level  of  the  sphincter  flows  slowly  over  it  into 
the  urethra  and  passes  drop  by  drop  through  the  stricture.  It  is  there- 
fore characteristic  of  this  incontinence  that  the  urine  is  not  voided  in 
large  quantities,  but  is  passed  in  drops,  so  that  the  patient  is  constantly 
wetting  his  clothing. 

A  highly  unpleasant  occurrence  is  the  development  of  sudden  com- 
plete retention  in  which  the  patient  cannot  void  a  drop  of  urine.  This 
condition  is  not  entirely  dependent  upon  total  occlusion  of  the  urethra, 
for  it  happens  sometimes  when  the  stricture  is  not  very  tight;  it  may  then 
be  due  to  spasm,  or  to  engorgement  superimposed  upon  the  contrac- 
tion. A  cold  or  the  free  use  of  alcohol  may  cause  such  congestion  or 
spasm. 

The  urine  of  men  affected  with  stricture  is  usually  not  clear.  Owing 
to  impingement  of  the  urinary  stream  upon  the  narrowed  spot,  the 
latter  together  with  the  portion  of  the  urethra  behind  it  becomes  inflamed, 
as  a  result  of  which  the  secretion  is  augmented  and  becomes  mixed  with 
the  urine,  in  which  it  appears  as  flakes  or  filaments.  Oftentimes  this 
catarrhal  process  extends  backward  into  the  bladder  and  causes  a  cystitis, 
which  produces  turbidity  of  the  urine. 

In  most  cases  the  symptoms  and  signs  already  mentioned  are  suffi- 
cient to  make  a  diagnosis  of  stricture  probably  correct,  although  they 
must  not  be  entirely  depended  upon,  for  narrow  stream,  slow  micturi- 
tion,  pain,    incontinence,    and    retention    occur  in    other  affections, 


PROGNOSIS    OF    STRICTURE.  1 39 

notably,  in  paralysis  of  the  bladder  and  hypertrophy  of  the  prostate.  A 
physical  examination  must  always  be  made. 

This  consists  in  passing  a  soft,  not  too  small  olivary  bougie  into  the 
urethra.  I  advise  against  the  use  of  bougies  aboule,  also  called  stricture- 
searchers,  because  they  easily  become  caught  at  the  bulb  even  in  the 
healthy  urethra,  and  thus  are  not  adapted  to  discrimination  between  the 
normal  and  the  diseased.  The  ordinary  French  silk-web  bougies  with 
olivary  tip  may  better  be  used,  as  they  always  pass  through  the  healthy 
urethra  into  the  bladder.  If  they  are  arrested  anywhere  choose  smaller 
ones  until  a  size  is  found  which  just  exactly  passes.  This  one  will  repre- 
sent the  size  of  the  stricture. 

If  several  strictures  are  present  a  wide  one  behind  one  which  is  nar- 
row cannot  be  diagnosticated. 

After  the  diagnosis  of  stricture  is  made  the  general  condition  of  the 
patient  must  be  investigated,  because  stricture  has  a  whole  series  of 
complications  and  sequels  following  in  its  train. 

We  have  already  spoken  of  dilatations  and  pouches  behind  the  stricture, 
and  the  inflammatory  softening  which  occurs  in  them.  If  urine  collects 
in, these  pockets  it  may  undergo  decomposition  and  lead  to  inflammatory 
changes  in  the  tissue,  giving  rise  to  a  condition  which  is  known  as  phleg- 
mon when  it  affects  the  superficial  structures  and  as  urinary  infiltration 
when  it  involves  the  deep  parts.  The  tissue  becomes  disintegrated  by 
pus,  the  phlegmonous  process  forces  its  way  more  and  more  toward  the 
surface,  and,  unless  promptly  interfered  with,  breaks  externally  and 
forms  a  urinary  fistula.  Loss  of  substance  corresponding  to  the  size  of 
the  gangrenous  slough  occurs  in  the  urethra  and  its  coverings. 

The  destructive  process  is  effectuated  inexactly  the  same  manner  when 
a  follicle  behind  the  stricture  inflames,  suppurates,  and  becomes  filled 
with  decomposed  urine,  or  when  the  impingement  of  the  urinary  stream 
produces  a  tear  behind  the  stricture,  or  injury  is  inflicted  by  making  a 
false  passage.  In  all  these  cases  a  rapidly  progressing  infiltration  of 
urine  leading  to  gangrene  may  supervene. 

If  the  infiltration  begins  at  any  point  in  front  of  the  bulb,  swelling, 
redness,  and  subsequent  discoloration  will  develop  on  the  penis  and 
scrotum.  The  phlegmon  may  extend  upward  as  far  as  the  epigastrium. 
I  once  saw  suppuration  at  the  arch  of  the  ribs.  If  the  point  of  egress 
be  behind  the  bulb,  the  urine  will  infiltrate  from  the  perineum  backwards 
toward  the  rectum,  peritoneum,  and  bladder.  A  pericystitis  with  its 
attendant  danger  of  rupture  into  the  peritoneal  cavity  is  present. 


I40  DISEASES    OF    THE    URETHRA    AND    PENIS. 

If  the  process  progresses  in  this  acute  manner  it  is  accompanied 
by  high  fever;  chills  and  elevation  of  temperature  as  high  as 
410  C.  [105.8  F.]  often  occur. 

More  frequently,  however,  the  process  is  slower  in  its  development. 
On  the  perineum  firm,  hard  swellings  of  irregular  form  are  found,  which 
to  the  inexperienced  give  the  impression  of  new  growths.  The  usual 
termination  of  such  slowly  progressive  inflammations,  provided  that  they 
do  not  become  diffuse  and  form  infiltrations,  is  urinary  abscess,  which 
if  it  is  not  opened  seasonably,  may  gradually  involve  the  contiguous 
tissues  and  lead  to  urinary  fistula.  The  diagnosis  of  all  these  conditions 
will  not  be  difficult  if  the  urethra  be  examined  and  the  presence  of  a 
stricture  determined,  for  then  the  relatively  rapid  development  of  the 
swelling  can  be  accounted  for. 

Very  often,  as  has  already  been  stated,  the  stricture  is  associated  with 
cystitis.  This  cystitis  does  not  differ  from  the  ordinary  forms  {quod 
vide).  It  heals  very  rapidly  as  soon  as  the  stricture  is  relieved,  so  that 
oftentimes  no  special  treatment  is  needed,  dilatation  of  the  stricture  in 
itself  sufficing  to  produce  a  cure. 

In  consequence  of  the  resistance  which  the  musculature  of  the  bladder 
has  to  overcome  in  forcing  the  urine  through  a  contracted  passage  it 
very  frequently  hypertrophies.  In  most  cases  of  narrow  stricture  of 
long  duration  this  condition  of  the  bladder  will  be  revealed  by  the  cysto- 
scope  after  the  narrowing  has  been  overcome. 

If  the  obstruction  lasts  very  long  it  may  cause  dilatation  of  the  upper 
urinary  tract.  The  ureters  become  dilated  and  the  pelvis  of  the  kidneys 
distended  into  a  sac. 

Under  such  conditions  infection  is  not  long  postponed;  the  dilated 
ureters  become  inflamed  and  the  hydronephrosis  becomes  converted 
into  a  pyonephrosis. 

That  the  inflammatory  process  in  the  posterior  urethra  often  extends 
into  the  duct  of  the  glands  the  same  as  in  posterior  gonorrhoea  is 
easily  understood;  we  observe,  therefore,  during  the  course  of  stricture, 
epididymitis,  prostatitis,  and  spermatocystitis. 

The  prognosis  of  urethral  stricture  is  on  the  whole  favorable, 
although  it  depends  somewhat  upon  the  kind  of  stricture  and  its 
location. 

The  further  forward  a  stricture  lies  the  more  difficult  it  is  to  cure, 
so  that  those  situated  near  the  meatus  are  the  most  unfavorable  of  all. 
Gonorrhceal  strictures  are  much  more  benign  than  traumatic.     The 


TREATMENT    OF    STRICTURE.  141 

latter  are  very  obstinate  and  often  difficult  to  influence.     All  depends 
upon  the  nature  of  the  causative  injury. 

Complications  endangering  life  generally  arise  as  the  result  of 
neglect.  If  a  stricture  is  carefully  watched  and  the  caliber  of  the 
urethra  properly  kept  open,  these  complications  do  not  arise  even 
though  the  stricture  is  not  cured.  If  the  condition  be  allowed  to  go 
untreated  for  years,  it  leads  to  the  above  described  processes,  such  as 
urinary  infiltration,  fistula?,  hydronephrosis,  pyonephrosis,  etc. 

TREATMENT. 

The  treatment  of  urethral  stricture  is  one  of  the  most  satisfactory 
tasks  of  the  surgeon.  With  proper  skill  nearly  all  cases  can  be  quickly 
helped. 

It  is  self-evident  that  treatment  must  be  solely  mechanical  and  di- 
rected to  re-establishing  the  caliber  of  the  urethra. 

We  set  forth  beforehand  that  cure  in  an  anatomical  sense  is  hardly 
ever  possible.  We  have  to  do  with  a  narrow  canal,  the  passage 
through  which  is  contracted  by  the  formation  of  scar-tissue.  The 
scars  can  be  dilated  and  enlarged,  but  as  every  scar  has  an  inherent 
tendency  to  contract  there  will  always  be  danger  of  their  becoming 
narrow  again.  Only  in  those  cases  in  which  the  stricture  can  be 
entirely  cut  out  and  the  free  ends  of  the  urethra  re-united  can  a  cure 
in  the  anatomical  sense  of  the  word  be  spoken  of. 

We  must  be  satisfied  with  effecting  a  cure  in  the  clinical  sense,  that  is, 
improving  the  patient's  condition  by  freeing  him  from  all  difficulty  and 
keeping  him  free  for  a  long  time.     This  is  thoroughly  feasible. 

The  methods  of  treating  stricture  may  be  divided  into  three  groups : 
1.  forcible  bursting  of  the  stricture,  which  is  known  as  the  divulsion 
method;  2.  dilatation;  3.  operative  procedures  by  which  the  stricture  is 
divided  or  cut  away. 

We  will  mention  divulsion  methods  first  so  as  to  dismiss  them  from 
consideration.  They  are  antiquated,  their  employment  is  irrational, 
and  they  are  productive  of  harm  rather  than  of  good.  An  appreciation 
of  the  morbid  anatomy  of  stricture  will  of  itself  suffice  to  show  that 
forcible  rupture  of  a  stricture  will  cause  a  new  scar  to  form,  and  there- 
fore increase  rather  than  relieve  the  contraction  of  the  urethra.  For 
this  reason  we  will  omit  a  description  of  the  various  instruments 
devised  for  divulsion;  they  are  solely  of  historical  interest. 

For  the  same  reason  I  am  opposed  to  the  electrolytic  method  of 


142  DISEASES    OF    THE    URETHRA    AND    PENIS. 

treating  stricture.  Formerly  strictures  were  often  treated  with  caustics. 
Attempts  were  made  to  bore  a  passage  through  with  these  substances, 
but  the  method  was  abandoned  because  it  was  seen  that  cauterization 
as  well  as  forcible  rupture  must  later  prove  advantageous  to  the  process 
of  contraction.  I  am  of  the  opinion  that  the  treatment  of  stricture  by 
electrolysis  can  be  no  more  successful  than  treatment  with  any  other 
caustic;  in  the  one  instance  cauterization  is  effected  with  chemicals,  in 
the  other  with  the  electric  current. 

The  above  mentioned  procedures,  moreover,  are  not  at  all  necessary, 
as  the  majority  of  all  strictures  can  be  successfully  treated  by  dilatation. 

We  distinguish  gradual  temporary  dilatation,  and  continuous 
dilatation. 

Gradual  temporary  dilatation  is  the  proper  procedure  for  nearly  all 
strictures.  It  consists  in  introducing  into  the  bladder  a  soft  silk-web 
bougie  of  such  a  size  that  the  stricture  will  just  admit  of  its  passage. 
The  instrument  is  allowed  to  remain  in  the  urethra  for  a  few  minutes ; 
to  leave  it  in  longer  is  of  no  advantage.  At  the  next  treatment,  which  is 
best  given  on  the  second  day,  the  same  bougie  is  passed  once  and  then 
the  next  larger  number  is  introduced.  The  employment  of  any  force 
whatsoever  is  wrong;  the  stricture  must  be  slowly  stretched,  not  torn. 
With  this  gradual  dilatation  much  better  and  safer  results  will  be 
obtained  than  if  the  stricture  be  forcibly  enlarged  at  one  sitting  by 
using  several  instruments.  From  the  latter  course  chills  and  fever  not 
uncommonly  result.  Moreover,  if  the  stricture  is  net  causing  urgent 
symptoms  there  is  no  indication  for  rapidly  widening  it.  Treatment 
should  be  continued  slowly  and  gradually  until  the  urethra  will  admit 
a  good  sized  bougie  (21-23  F.). 

[American  surgeons  continue  the  dilatation  much  higher.  If  the 
meatus  be  too  small  to  admit  sounds  of  large  caliber,  meatotomy  may 
be  done  or  recourse  had  to  dilators.  With  Kollmann's  dilators  it 
will  be  found  possible  to  attain  a  higher  degree  of  dilatation  than 
with  sounds.  The  minimum  dilatation  which  I  eventually  reach 
with  these  instruments  is  30  F.] 

As  before  stated  only  soft  olivary  bougies  should  be  used.  Metal 
sounds  are'also  employed,  but  I  do  not  deem  it  advisable  to  use  a  smaller 
one  than  16  F.  because  the  slenderness  and  rigidity  of  the  tip  of  smaller 
sizes  make  the  danger  of  forcing  a  false  passage  too  great;  even 
the  greatest  skill  and  gentleness  will  not  always  prevent  the  point 
from  catching  in  a  lacuna  and  then  making  a  false  passage  if  it  be 


TREATMENT    OF    STRICTURE.  I43 

pushed  onward.  In  these  cases,  therefore,  I  always  use  the  soft  French 
olivary  bougies.  A  great  deal  depends  upon  the  tip  of  the  instrument. 
It  must  rest  upon  a  neck  which  is  thinner  than  the  body  of  the  instru- 
ment. By  this  construction  considerable  mobility  of  the  tip  is  obtained, 
which  makes  it  easier  for  it  to  find  its  way  through  the  stricture. 
The  pointed  conical  French  bougies  are  to  be  utterly  discarded.  I 
know  of  no  instrument  which  can  do  great  damage  as  easily  as  these. 
The  point  seems  to  be  made  for  catching  in  a  fold  of  mucous  mem- 
brane or  in  the  opening  of  a  gland. 

The  after  treatment  of  these  cases  is  very  important  It  consists 
in  passing  a  bougie  at  certain  intervals  so  that  the  caliber  to  which 
the  urethra  has  been  dilated  may  be  maintained.  At  first  the  instru- 
ment should  be  passed  every  two  weeks,  later  every  four  weeks,  and 
if  the  same  size  passes  readily  the  intervals  may  then  be  increased 
to  three  or  six  months  or  even  a  year.  Intelligent  patients  can  be 
taught  to  carry  out  this  treatment  themselves. 

Although  this  procedure  will  suffice  for  the  majority  of  strictures, 
which  may  be  designated  as  light  cases,  there  are  a  certain  number  in 
which  the  first  requisite  of  the  method,  namely,  the  introduction  of  a 
bougie,  however  small,  cannot  be  accomplished. 

The  difficulty  may  depend  upon  inability  to  find  the  opening  of  the 
stricture,  or  upon  the  impossibility  of  penetrating  the  stricture  because 
of  its  narrowness,  after  the  bougie  has  entered  the  opening.  These 
are  two  entirely  different  conditions  which  demand  a  totally  different 
method  of  procedure.  In  the  latter  case,  when  the  tip  of  the  instru- 
ment has  entered  the  stricture  but  will  not  advance,  it  should  be  left  in 
situ  for  a  while,  after  which  an  attempt  to  pass  it  will  often  prove  suc- 
cessful; it  may  be  allowed  to  remain  as  long  as  an  hour.  Under  these 
circumstances  a  certain  amount  of  force  may  be  employed  until  the 
tip  of  the  instrument  is  pushed  through  the  constriction.  When  the 
instrument  is  actually  in  the  opening  of  the  stricture  injury  can  hardly 
result  by  pushing  it  through.  The  employment  of  force  is  not  per- 
missible, however,  unless  one  is  absolutely  certain  of  the  position  of 
the  bougie.  If  any  doubt  remain  that  the  tip  of  the  instrument  is  not 
in  the  opening  of  the  stricture,  then  the  employment  of  force  becomes  a 
gross  error,  which  can  cause  nothing  but  harm;  it  is  then  our  duty 
to  find  the  opening,  for  which  patience  and  delicacy  of  touch,  but 
not  force,  are  helpful.  The  cause  of  this  difficulty  in  entering  the 
stricture  is  generally  due  to  the  fact  that  its  opening  is  not  central  in 


144 


DISEASES    OF    THE    URETHRA    AND    PENIS. 


the  axis  of  the  urethra,  but  is  eccentric;  the  opening,  too,  may  be  so 
narrow  that  the  instrument  cannot  penetrate  it. 

In  the  latter  case  it  is  well  to  inject  a  small  syringeful  of  olive-oil 
into  the  urethra  and  then  introduce  a  filiform  bougie.  The  oil  enlarges 
the  opening  so  that  the  instrument  can  often  be  made  to  enter  it.  The 
same  difficulty  is  encountered  in  passing  an      instrument  through 


Jf 


Fig.  134 — Spiral  and 
bayonet-bougies 


Fig.  134. — False  passage  in  the  urethra. 


spiral  strictures.  The  point  of  a  straight  bougie  naturally  strikes 
against  the  wall  of  the  stricture.  Therefore  an  attempt  should  be  made 
to  pass  a  spiral  or  bayonet  filiform  (Fig.  134). 

If  the  stricture  is  eccentric  and  its  opening  cannot  be  found,  the 
artifice  of  introducing  several  bougies  down  to  the  stricture  and  then 
patiently  and  gently  trying  to  work  one  into  the  opening  may  be  tried 


TREATMENT    OF    STRICTURE.  145 

with  advantage.  The  value  of  this  procedure  has  long  been  known, 
and  it  will  often  succeed  after  all  other  measures  have  failed.  This  is 
easily  explained.  While  the  point  of  a  single  filiform  strikes  against 
the  wall  of  the  urethra,  if  four  be  introduced  it  is  probable  that  one  will 
hit  the  opening.  At  least  the  chances  of  such  an  occurrence  are 
favorable,  for  if  three  of  the  bougies  miss  the  opening  the  chances  of 
the  fourth  one  reaching  it  are  increased.  [It  may  be  necessary  to  fill 
the  urethra  completely  with  filiforms  and  then  try  to  insinuate  first 
one  and  then  another  through  the  orifice  of  the  stricture.] 

Frequently  the  difficulty  of  entering  the  stricture  is  due  to  the 
presence  of  one  or  more  false  passages.  (Fig.  135.)  The  diagnosis  of 
such  a  case  is  not  easy,  although  there  are  certain  criteria  which  are 
of  assistance,  such  as  deviation  of  the  bougie  from  the  median  line, 
perception  of  an  unusually  thin  layer  of  tissue  between  the  rectum  and 
the  bougie,  and  especially  sudden  arrest  of  the  bougie  after  it  has  been 
passed  18  cm.  [7 \  inches]  or  more  into  the  urethra.  This  sudden 
arrest  is  evidence  that  the  instrument  is  not  in  the  bladder.  Since 
strictures  do  not  occur  behind  the  membranous  urethra,  and  as  the 
distance  from  the  meatus  hitherto  seldom  exceeds  17  cm.  [6f  inches] 
the  bougie  must  have  penetrated  the  mucosa,  that  is,  entered  a 
false  passage.  The  only  other  possibility  is  that  the  bougie  may 
have  entered  the  stricture  and  is  firmly  held  there.  This  condition 
cannot  be  confounded  with  the  one  just  described,  because  the  clasping 
of  the  instrument  by  the  stricture  can  be  distinctly  felt,  whereas  when 
in  a  false  passage  it  can  be  rotated  on  its  axis.  If  the  point  be  caught 
in  a  pocket  of  the  retiform  tissue  behind  the  stricture,  it  will  generally 
be  possible  to  pass  it  into  the  bladder  by  drawing  it  out  a  little,  turning 
it  on  its  axis,  and  then  pushing  it  onward  again. 

The  difficulty  of  passing  a  bougie  when  such  a  complication  is  present 
consists  in  the  almost  invariable  tendency  of  the  instrument  to  seek 
the  false  rather  than  the  true  passage.  In  such  cases  I  have  found  the 
following  artifice  of  value:  I  introduce  a  moderately  slender  bougie, 
one  about  6  French,  as  deep  as  it  will  go  without  forcing  it.  It  will 
almost  always  enter  the  false  passage.  With  this  one  still  in  place  a 
second  one  introduced  beside  it  will  often  enter  the  stricture.  This 
is  explained  by  the  fact  that  the  false  passage  is  occluded  by  the  first 
instrument  so  that  the  second  passes  nolens  volens  into  the  true  opening. 

With  the  help  of  all  these  measures  it  will  often  be  possible  to  over- 
come strictures  which  at  first  seemed  impermeable,  and  when  they 


146  DISEASES    OF    THE    URETHRA    AND    PENIS. 

have  once  been  passed  to  proceed  to  further  dilatation.  There  are 
cases,  however,  in  which  these  gradual  procedures  fail.  There  are 
circumstances,  too,  which  absolutely  indicate  rapid  dilatation.  For 
example,  if  a  purulent  cystitis  with  stinking,  sanious  urine  is  present, 
or  an  inflammation  of  the  upper  urinary  tract  with  attacks  of  fever, 
then  a  more  rapid  subjugation  of  the  stricture  is  necessary.  An 
appropriate  procedure  here  is  continuous  dilatation. 

It  consists  in  passing  a  catheter  one  size  smaller  than  the  stricture 
into  the  bladder  and  fastening  it  there.  This  catheter,  which  must  be 
only  a  soft  silk-web  one,  is  allowed  to  remain  from  twenty-four  to 
'forty-eight  hours.  Owing  to  the  continuous  contact  of  the  catheter 
with  the  stricture  an  inflammatory  process  develops  which  leads  to 
softening  of  the  callus  and  makes  it  possible  after  forty-eight  hours 
to  dilate  the  stricture  from  4  to  6  mm.  without  tearing  it.  The 
largest  instrument  passed  is  then  fastened  in  and  at  the  end  of  two 
days  another  rapid  dilatation  made,  and  so  forth.  In  this  way  stric- 
tures which  are  not  too  hard  can  be  brought  up  to  a  caliber  of  20  F. 
or  higher  in  a  week. 

If  the  stricture  is  so  narrow  that  recourse  must  be  had  to  filiforms 
one  should  be  tied  into  the  urethra.  The  patient  then  forces  his  urine 
;out  beside  the  bougie,  which  acts  in  the  same  manner  as  a  retained 
catheter. 

This  continuous  dilatation  is  a  good  method  for  quickly  overcoming 
soft  strictures,  but  is  appropriate  only  when  there  is  an  associated 
cystitis.  If  the  latter  be  absent  and  the  urine  clear,  it  is  contra-indi- 
cated. The  inflammation  excited  in  the  urethra  almost  always  extends 
to  the  bladder.     This  viscus  becomes  infected  and  cystitis  develops. 

Whenever  a  catheter  is  retained  the  bladder  must  be  irrigated 
several  times  daily  so  as  to  wash  out  some  of  the  germs  which  have 
gained  access  and  render  those  which  remain  innocuous.  An  injec- 
tion of  100  cc.  [about  3  fluid  ounces]  of  a  1 :  1000  silver  nitrate  solu- 
tion, alternating  with  mercury  oxycyanate  1 :  4000,  may  be  given  by  a 
nurse  every  two  hours  and  the  fluid  allowed  to  flow  out  through  the 
catheter. 

Another  very  valuable  and  gladly  employed  procedure  by  which  a 
permanent  catheter  is  inserted  is  that  of  Le  Fort.  The  methods  of 
Desault  and  Maisonneuve  were  the  precursors  of  this  one  which  we 
are  about  to  describe. 

The  multifarious  measures  which,  as  we  have  seen,  are  at  times  neces- 


TREATMENT    OF    STRICTURE.  1 47 

sary  to  gain  entrance  to  a  stricture  show  how  difficult  entrance  may  often 
be.  Therefore  it  is  not  surprising  that  surgeons  long  since  endeavored 
to  render  permanent  any  opening  which  they  once  succeeded  in  making. 
It  can  happen,  says  Thompson,  that  the  most  skillful  surgeon  may  fail 
to  get  an  instrument  through  a  stricture  after  having  once  successfully 
penetrated  it.  Acting  in  accordance  with  this  knowledge  Desault 
used  a  thin  elastic  catheter  open  at  both  ends,  which  he  pushed  down  as 
far  as  the  stricture,  and  then  tried  to  pass  another  through  it  into  the 
bladder.  Over  this  he  then  endeavored  to  slide  a  larger  instrument. 
Maisonneuve's  well-known  procedure  was  an  improvement  on  De- 
sault's.  After  he  had  succeeded  in  passing  a  slender  guiding  sound 
into  the  bladder  he  screwed  a  somewhat  thicker  flexible  bougie  onto  its 
external  end  and  then  pushed  it  through  the  urethra,  whereupon  the 
first  one  became  coiled  up  in  the  bladder.  Upon  the  second  instru- 
ment there  followed  a  third  larger  one,  and  so  on  until  the  stricture  was 
considerably  dilated  at  a  single  sitting. 

Both  these  methods  are  to  be  rejected  because  they  are  nothing  more 
nor  less  than  skillfuly  performed  divulsions,  which,  as  already  stated, 
we  consider  injurious. 

Le  Fort's  method  differs  from  Maisonneuve's  only  in  that  Le  Fort 
allows  the  filiform  guide  to  remain  in  the  urethra  from  twenty-four  to 
forty-eight  hours  before  attaching  and  passing  the  second  instrument, 
which  is  preferably  a  metal  catheter  such  as  is  shown  in  Figure  136. 
Le  Fort  aims  to  create  inflammatory  softening  of  the  stricture  by  means 
of  the  retained  catheter,  and  thereby  prepare  the  way  for  larger  instru- 
ments. It  is  not  successful  in  the  sense  that  the  metal  instrument 
can  always  be  passed  the  next  day  without  the  employment  of  any  force, 
but  yet  it  is  a  very  good  method  which  can  be  used  in  many  cases  with 
great  benefit. 

A  slight  application  of  force  is,  moreover,  permissible  because  we  are 
certain  that  the  instrument  is  within  the  stricture  so  that  a  false  passage 
cannot  be  made.  It  is  only  when  too  much  haste  or  force  is  used  that 
the  filiform  can  nick  the  urethra;  if  under  such  circumstances  it  be 
pushed  onward  great  harm  will  naturally  be  done. 

Varnished  silk- web  catheters  are  now  manufactured  which  corre- 
spond to  Le  Fort's  instrument.  The  anterior  part,  about  30  cm. 
[12  inches]  is  filiform,  while  the  remaining  portion  increases  gradually 
into  a  thick  large  shaft  [Rat-tail  catheter].  (Fig.  137.)  This  instru- 
ment can  often  be  passed  when  Le  Fort's  metal  catheter  fails.     It  may 


148 


DISEASES    OF    THE    URETHRA    AXD    PENIS. 


be  impossible,  however,  to  overcome  very  indurated  strictures;  the 
softening  produced  by  retention  of  the  filiform  is  too  slight  to  admit 
the  passage  of  either  the  attached  metal  instrument  or  the  gradually 
thickening  soft  catheter.  Moreover,  there  are  many  circumstances 
under  which  it  is  not  advisable  to  employ  any  of  the  above-named 


Fig.  136. — LeFort's 
instrument. 


Fig.  137. — Rat-tail  catheter. 


methods,  and  which   compel  us   to  treat   the   stricture  by  operative 
measures. 

Of  these  we  will  first  mention  hypersensibility  of  the  urethra, 
which  manifests  itself  by  derangement  of  the  nervous  system.  There 
are  patients  who  experience  disturbances  in  various  organs  after  every 
catheterization,  no  matter  how  carefully  it  may  be  performed.    Apart 


TREATMENT    OF    STRICTURE.  1 49 

from  the  intolerable  pain  caused  by  the  passage  of  the  instrument  there 
remains  for  a  considerable  time  an  irritability  of  the  urethra  which  inca- 
pacitates the  patient  for  work,  deprives  him  of  appetite,  and  robs  him 
of  sleep.  Slight  attacks  of  syncope  and  symptoms  of  shock  occur.  If 
several  soundings  attest  the  permanency  of  this  state  of  hypersen- 
sibility  and  the  usual  antagonistic  measures  such  as  preliminary 
cocainization  of  the  urethra  remain  without  effect,  we  must  desist  from 
attempts  at  dilatation. 

Urethral  fever  must  not  be  confounded  with  this  shock-like  con- 
dition. It  occurs  in  three  forms :  first  as  a  single  transitory  attack  of 
fever;  second  as  a  recurrent  fever;  third  as  a  chronic  continuous  fever. 
Cases  of  this  kind  occurring  after  the  passage  of  instruments  are  at 
present  regarded  exclusively  as  infectious;  they  indicate  the  presence 
of  renal  complications,  but  may  occur  independently  thereof.  In 
every  such  case  we  should  use  the  utmost  caution  in  employing  dilata- 
tion, or  even  resort  to  some  other  procedure  for  removing  the  stricture. 

A  second  condition  is  the  so-called  resilient  stricture,  which  shows 
a  tendency  to  contract  after  every  dilatation.  The  use  of  the  bougies 
here  amounts  to  nothing.  The  constriction  occurs  again,  and  even 
so  rapidly  as  to  demand  the  daily  passage  of  an  instrument  to  keep  the 
urethra  patulous. 

Some  authors  explain  this  condition  by  the  supposition  that  the 
resorptive  power  of  the  tissue  is  no  longer  present,  that  the  stricture 
is  composed  of  an  unalterable  dry  scar  which  always  contracts.  How- 
ever this  may  be,  the  fact  remains  that  such  strictures  are  not  suitable 
for  dilatation. 

In  like  manner  experience  has  demonstrated  that  strictures  near  the 
external  meatus  are  exceptionally  obstinate.  Dilatation  is  generally 
useless  and  also  very  painful.  They  are  conquered  much  more  easily 
and  quickly  by  a  free  internal  incision  with  a  small  blunt-pointed 
knife,  or  a  concealed  bistoury.  The  exceedingly  rare  valvular  stric- 
tures should  be  cut  (Fig.  138).  In  the  very  rarest  instances  they  are 
due  to  consolidation  of  free  masses  of  exudate  projecting  from  the 
surface  of  the  urethra,  but  generally  result  from  congenital  duplica- 
tion of  the  mucous  membrane.  Treatment  consists  in  dividing  the 
valve  with  a  fine-pointed  bistoury  on  a  tunnelled  sound. 

For  the  division  of  all  strictures  situated  further  back  special 
instruments  and  procedures  are  required.  We  distinguish  between 
internal  and  external  urethrotomy. 


IS© 


DISEASES    OF    THE    URETHRA    AND    PENIS. 


INTERNAL  URETHROTOMY. 


Internal  urethrotomy  is  performed  by  carrying  a  knife  into  the  urethra 
and  evenly  dividing  the  constricted  portion.  The  object  aimed  at  is  to 
cut  through  the  callous  or  contracted  scar-tissue  in  such  a  manner  that 


_  a 


„.a 


mm 
\M 

Fig.  138. — Valve-stricture.     Stricture  en  bride  of  Voillemier. 

a  new  layer  of  scar-tissue  shall  be  interposed  between  the  cut  edges,  with 
the  result  that  the  stricture  becomes  widened. 

Internal  urethrotomy  may  be  performed  from  behind  forward  or 
from  before  backward.  A  prototype  of  the  first  method  is  that  of 
Maisonneuve,  while  Thompson's  represents  the  second.     Many  other 


INTERNAL    URETHROTOMY.  151 

surgeons  have  devised  urethrotomes,  and  each  thinks  his  own  is 
the  best. 

The  construction  of  Thompson's  instrument,  which  cuts  from  behind 
forward,  is  shown  in  the  illustration  (Fig.  139).  The  blade  D  is  concealed 
in  the  sheath  C.  The  instrument  is  passed  through  the  stricture,  the 
blade  is  liberated  by  pressing  upon  B  and  the  instrument  is  then  drawn 
forward.  This  urethrotome,  the  caliber  of  which  about  corresponds 
to  No.  12  of  the  French  scale,  can  be  used  only  for  strictures  large 
enough  to  admit  of  its  passage.  I  am  of  the  opinion  that  a  stricture 
which  admits  a  No.  12  instrument  seldom  requires  bisection,  and 
therefore  do  not  employ  the  method. 

A  much  more  useful  procedure  is  that  of  Maisonneuve,  in  which  the 
incision  is  made  from  before  backward,  the  only  prerequisite  to  its  per- 

C  B  *    A 


Fig.  139. — Thompson's  urethrotome. 

formance  being  the  passage  of  a  filiform  bougie.  The  instruments 
necessary  are  shown  in  the  accompanying  illustration.  (Fig.  140.)  The 
filiform  bougie  (F)  is  introduced  into  the  bladder  and  allowed  to  remain 
twenty-four  hours.  Upon  the  end  of  this  the  urethrotome  (U)  is  attached 
by  means  of  a  screw- tip  and  pushed  through  the  urethra  into  the  bladder, 
whereupon  the  filiform  curls  up  in  the  bladder  the  same  as  in  Le  Fort's 
method.  The  knife  (M)  is  now  inserted  into  the  groove  of  the  shaft;  it 
cuts  only  forward  and  backward,  being  blunt  at  the  summit.  In  conse- 
quence of  this  procedure  the  urethra  is  stretched  wherever  it  is  dilatable, 
so  that  the  knife  does  not  cut  when  it  is  inserted  and  withdrawn.  In  the 
places  where  the  urethra  cannot  expand  it  cuts  through  the  tissue.  There 
are  three  blades  of  different  sizes,  M,  Mi,  M2,  to  be  used  according  to 
the  extent  of  the  incision  it  is  desired  to  make.  The  knife  is  carried 
down  to  the  internal  sphincter  and  then  withdrawn,  cutting  as  it  returns 
any  contractions  not  previously  divided.  The  shaft  of  the  instrument 
is  now  withdrawn  until  the  filiform  attached  to  its  end  appears  at  the 
meatus;  the  staff  (St.)  is  now  fastened  to  the  filiform,  and  over  it  the  cath- 
eter (K)  is  slipped  and  passed  into  the  bladder;  finally  the  staff  and 
filiform   are  withdrawn   and   the  catheter  fastened  into  the  bladder 


1^2 


DISEASES    OF    THE    URETHRA    AND    PENIS. 


=>3 


Ftg.  140. — Maisonneuve's  urethrotome. 


EXTERNAL    URETHROTOMY.  I  53 

and  kept  there  for  three  days.  This  method  is  an  excellent  one,  suc- 
ceeding in  nearly  all  cases,  even  in  those  in  which  the  strictures  are 
considerably  indurated.  It  may  happen,  however,  that  the  catheter 
cannot  be  slipped  over  the  filiform  if  the  calloused  masses  are 
very  large. 

Moreover,  the  procedure  is  not  entirely  without  danger,  and  therefore 
is  to  be  resorted  to  only  when  urgently  indicated  and  after  the  other  and 
milder  methods  have  failed.  The  danger  lies  first  in  the  possibility  of 
infection  taking  place  through  the  incision,  and  secondly  in  the  pro- 
pensity to  violent  haemorrhage,  most  difficult  of  control.  I  have  seen 
both  conditions. 

In  the  first  instance  chills  occur;  this  is  not  of  much  import  if 
only  one  takes  place,  but  the  condition  responsible  for  their  occurrence 
may  develop  into  a  true  sepsis,  especially  if  a  purulent  cystitis  be  present. 
It  is  well  to  give  i.o  [15  grains]  of  quinine  before  and  after  the 
operation. 

Copious  haemorrhages  are  more  frequent.  The  operation  is  done  in 
the  dark,  as  it  were,  and  the  size  of  the  incision  canot  be  measured.  It 
may  open  the  corpora  cavernosa  widely,  so  that  a  continuous  and  uncon- 
trollable oozing  of  blood  will  take  place" from  the  urethra.  These  haem- 
orrhages are  particularly  malign  because  the  source  of  the  bleeding 
cannot  be  reached.  Compression  of  the  urethra  upon  the  catheter,  and 
injections  of  gelatine  may  be  tried;  if  they  do  not  succeed  external 
urethrotomy  must  be  performed  and  the  bleeding  spot  tamponed 
through  the  opened  urethra. 

Do  not  be  deceived  by  the  absence  of  haemorrhage  from  the  meatus,  as 
the  blood  often  flows  backward  into  the  bladder.  A  flow  of  clear  urine 
free  from  blood  through  the  retained  catheter  is  proof  that  haemorrhage 
is  not  occurring.  Severe  haemorrhages  may  even  develop  days  after  the 
operation  and  upon  these  likewise  must  great  attention  be  bestowed. 

EXTERNAL    URETHROTOMY. 

External  urethrotomy  is  reserved  for  those  rare  cases  in  which  the 
milder  procedures  already  described  have  failed. 

The  method  of  performing  it  varies  according  to  whether  the  urethra 
will  admit  the  passage  of  an  instrument.  In  those  cases  in  which  the 
operation  is  done  for  urinary  abscess  caused  by  infiltration  of  urine, 
and  in  which  a  metal  sound  passes  through,  it  is  extremely  simple,  a 
tunnelled  staff  (Fig.   141)  being  passed  into  the  bladder,  the  urethra 


154 


DISEASES    OF    THE    URETHRA    AND    PENIS. 


opened  in  the  groove  of   the  staff  and  the  stricture  divided  [Syme's 

operation]. 

Its  performance  is  much  more  difficult  when  only  a  filiform  can  be 

passed;  in  this  condition  the  incision  must  be  made  exactly  in  the 
median  line  in  an  endeavor  to  cut  down  upon  the 
filiform.  As  the  urethra  is  often  distorted  it  may 
be  difficult  to  find  the  bougie  through  the  incision, 
although  with  care  and  patience  the  difficulty  can 
always  be  overcome. 

On  the  other  hand,  when  no  instrument  what- 
ever can  be  passed  through  the  urethra  the  opera- 
tion may  be  exceedingly  difficult.  A  metal  sound 
is  carried  into  the  urethra  as  far  as  it  will  go,  an 
incision  made  down  to  its  tip  and  the  urethra 
opened;  the  edges  are  then  drawn  apart  with 
forceps,  or  retracted  and  fastened  with  a  thread, 
and  the  further  course  of  the  urethra  sought  for 
with  a  fine  bougie.  The  effort  is  generally  suc- 
cessful and  the  operation  is  then  carried  out  as 
before  described;  it  is  not  completed,  however, 
until  a  large  Nelaton  or  French  catheter  is  passed 
into  the  bladder  through  the  perineal  wound  and 
the  urine  flows  out  freely.  [A  perineal  drainage 
tube  may  be  substituted  for  either  of  these  instru- 
ments, or  a  catheter  may  be  passed  from  the  meatus 
(Fig.  142).  The  introduction  of  a  gorget  (Fig.  143) 
into  the  bladder  through  the  perineal  wound  will 
facilitate  the  introduction  of  the  catheter  or  drain- 
age tube.  Pass  the  gorget  in  before  removing  the 
staff,  then  withdraw  the  staff  and  insert  the  catheter 
or  drainage-tube.]  If  the  course  of  the  urethra 
cannot  be  determined  after  the  distal  end  of  the 
stricture  has  been  exposed,  suprapubic  cystotomy 
may  be  performed  as  a  last  resort  and  retrograde 
catheterization  practised.    After  the  bladder  has  been 

opened  a  metal  catheter  or  staff  is  inserted  into  the  internal  orifice  of  the 

urethra  and  carried  outward  until  its  tip  appears  in  the  perineal  wound ; 

a  catheter  is  now  passed  from  the  external  meatus  and  fastened  onto  the 

tip  of  this  instrument,  which  is  then  drawn  backward  so  that  the  catheter 


Fig.  141. — Syme's  staff. 


EXTERNAL    URETHROTOMY. 


J55 


is  carried  into  the  bladder.  The  catheter  is  carefully  fastened  and  the 
bladder  closed.  The  best  instrument  for  this  purpose  is  Jacques's  patent 
catheter,  which  must  be  left  in  for  two  or  three  weeks. 

[Orville  Horwitz  has  devised  an  instrument  which  facilitates  the  per- 
formance of  external  urethrotomy  for  very  tight  strictures  or  rupture  of 
the  urethra. 


Fig.  142. — Perineal  drainage  tube; 


Fig.  143. — Teale's  probe-gorget. 


Fig.  144. — Horwitz's  dilator  for  whip-bougie;  blades  closed. 

&  <?  ct 


Fig.  145. — Horwitz's  dilator  over  whip-bougie;  blades  separated. 


Fig.  146. — Horwitz's  dilator  over  a  filiform  bougie;  blades  separated. 

This  instrument  (Fig.  144)  consists  of  two  blades  (c)  in  cloee  approxi- 
mation, which  together  form  a  smooth  staff  with  a  thumb-  screw  (a)  at 
one  end,  by  means  of  which  the  blades  may  be  readily  separated. 
The  distal  end  of  the  staff  terminates  in  a  rounded  nut  (e)  which  can 
be  removed  and  replaced  by  a  whip  filiform  (Fig.  145).     An  opening 


156  DISEASES    OF    THE    URETHRA    AND    PENIS. 

(d,  Fig.  146)  in  the  nut  also  permits  the  insertion  of  a  filiform  bougie, 
which  may  be  used  when  the  whip-bougie  cannot  be  passed  through 
the  obstruction.  The  staff  is  inserted  into  the  urethra  until  the  obstruc- 
tion is  reached  and  the  bougie  is  then  pushed  onward  into  the  bladder. 
The  blades  of  the  instrument  are  then  separated,  as  a  result  of  which 
the  urethra  is  fixed  and  also  made  prominent,  so  that  it  can  be  readily 
detected  and  opened.] 

RESECTION    OF    THE    URETHRA. 

More  radical  than  simple  external  urethrotomy  are  those  procedures 
in  which  the  stricture  is  excised.  In  order  to  prevent  recurrence  and  the 
formation  of  fistula?  the  plan  of  cutting  out  the  entire  stricture  and 
uniting  the  free  ends  of  the  urethra  has  been  tried. 

The  operation  begins  with  an  external  urethrotomy.  After  the  urethra 
has  been  exposed  the  strictured  tissue  is  partly  or  entirely  cut  away. 
The  procedures  confined  merely  to  the  removal  of  masses  of  periurethral 
callus  do  not  come  under  this  operation,  which  consists  in  removing  the 
strictured  portion  of  the  urethra  itself.  The  entire  circumference  of  the 
constricted  part  is  usually  cut  through,  although  in  some  cases  it  may  be 
possible  to  remove  only  a  part  and  leave  the  roof  of  the  urethra  intact. 
After  the  stricture  has  been  excised  the  free  edges  of  the  urethra  may  be 
united  with  a  fine  suture,  or  a  new  canal  may  be  made  by  sewing  some  of 
the  soft  periurethral  tissue  over  a  catheter,  the  latter  method  being  prac- 
tised when  too  much  of  the  urethra  has  been  resected  to  allow  the  cut 
ends  to  be  approximated. 

Plastic  operations  also  have  been  tried.  The  tissue  covering  the 
urethra,  including  the  skin,  have  been  used  to  supply  the  loss  in  con- 
tinuity engendered  by  the  resection,  and  mucous  membrane  from 
another  part  of  the  body,  or  from  another  person  or  an  animal  has 
likewise  been  used. 

•  From  all  these  complicated  operative  procedures  an  occasional 
successful  result  has  been  reported ;  they  have  not  been  generally 
adopted,  however,  and  indeed  it  maybe  said  that  there  is  hardly  any  need 
of  them  as  the  less  radical  methods,  including  external  urethrotomy, 
give  satisfactory  results. 

TREATMENT    OF    RETENTION    OF    URINE    DUE    TO    STRICTURE. 

The  occurrence  of  retention  of  urine  requires  special  therapeutic  con- 
sideration.    We  must  remember  in  the  first  place  that  it  is  not  always 


TREATMENT    OF    RETENTION    OF    URINE    DUE    TO    STRICTURE.     1 57 


very  narrow  strictures  which  give  rise  to  retention,  but  that  moderate 
constrictions  may,  if  subjected  to  some  detrimental  influence,  cause  a 
total  temporary  occlusion  of  the  urethra. 

In  numerous  cases  the  passage  of  a  bougie  through  the  stricture,  or 
even  into  its  opening,  will  restore  the  patient's  ability  to  urinate;  there 
are  some  cases,  however,  in  which  the  patient  cannot  urinate  after  the 
sound  is  withdrawn,  and  others  in  which  an  instrument 
cannot  be  passed  into  the  bladder. 

In  the  first  of  these  two  conditions,  namely,  when  the 
patient  cannot  urinate  after  the  withdrawal  of  a  fine 
bougie  which  has  been  successfully  passed  into  his 
bladder,  Maisonneuve's  procedure  is  advisable;  it 
applies,  of  course,  only  to  those  strictures  through 
which  nothing  but  a  very  fine  instrument  can  be 
passed,  for  were  they  permeable  to  one  of  large  caliber 
it  would  be  a  simple  matter  to  take  a  catheter  and 
draw  off  the  urine.  Very  slender  instruments,  even 
though  hollow,  do  not  allow  the  urine  to  escape.  In 
such  cases,  as  has  just  been  said,  Maisonneuve's  method 
of  passing  a  filiform  to  which  is  attached  a  soft  or 
metal  catheter  may  be  followed  (see  page  147).  It  is, 
indeed,  a  divulsion,  a  procedure  which  1  do  not  generally 
approve  of,  but  in  an  occurrence  so  pressing  and  urgent 
as  complete  retention  of  urine  it  is  permissible.  [In- 
stead of  employing  Maisonneuve's  method,  a  Gouley's 
tunnelled  catheter  (Fig.  147)  may  be  passed  over  a 
filiform.  If  it  is  impossible  to  get  any  instrument 
larger  than  a  filiform  through  the  stricture,  tie  in  the 
filiform,  as  it  will  abstract  some  of  the  urine  by  capillary 
drainage,  and  will  also  cause  inflammatory  softening 
of  the  indurated  tissue,  so  that  another  instrument  can 
be  passed  within  a  few  hours.  Oftentimes  Gouley's 
instrument  can  be  passed  at  the  second  attempt,  but  Fig.  i47.-Gouley's 

.„    ,        ,.  ,  .  tunnelled  catheter 

in  some  cases  it  will  be  found  necessary  to  insert  a 
second  filiform  beside  the  first,  and  even  to  employ  a  third,  before  a 
catheter  sufficiently  large  to  draw  off  the  urine  in  any  considerable 
quantity  can  be  introduced.  If  a  filiform  can  be  passed  and  capillary 
drainage  secured,  the  imperative  symptoms  will  be  relieved;  the  ob- 
struction can  generally  be  overcome  within  a  few  days  at  most.] 


158  DISEASES    OF    THE    URETHRA    AND    PENIS. 

For  those  most  urgent  cases  of  complete  retention  in  which  no 
instrument  whatsoever  can  be  passed  there  are  two  ways  which  lead 
to  the  goal:  either  an  immediate  external  urethrotomy  is  done  in  the 
manner  described,  or  a  palliative  capillary  puncture  of  the  bladder 
is  made. 

Of  the  two  operations  I  always  give  preference  to  the  latter.  As 
already  stated,  external  urethrotomy  without  a  guide  is  at  times  most 
difficult.  Not  infrequently  urinary  fistula  remains  as  a  sequel.  Punc- 
ture of  the  bladder  with  a  capillary  trocar  is  the  simplest  and  easiest 
procedure  that  there  is;  it  confers  relief  very  quickly  and  can  be  re- 
peated several  times  without  injury.  The  fine  puncture  in  the  bladder- 
wall  agglutinates  at  once.  If  several  have  been  made  and  the  bladder 
thus  relieved,  the  patient  will  either  be  able  to  urinate  voluntarily,  or 
a  bougie  can  be  passed  and  then  one  of  the  milder  procedures,  such  as 
Le  Fort's,  employed.  It  must  not  to  be  forgotten  that  it  is  not 
altogether  the  narrowness  of  the  stricture  which  is  responsible  for  the 
retention  of  urine;  we  have  often  seen  cases  in  which  distortion  of 
the  periurethral  masses  [exudate]  was  the  cause  of  the  extreme  nar- 
rowing, and  which  for  this  reason  were  readily  dilatable  by  Le  Fort's 
method. 

To  perform  vesical  puncture  take  an  ordinary  fine  trocar  somewhat 
longer  than  that  used  for  tapping  a  hydrocele  and,  after  incising  the 
skin  just  above  the  symphysis  under  local  anaesthesia,  thrust  it  quickly 
into  the  bladder.  The  peritoneum  is  pushed  upward  by  the  distended 
bladder  and  remains  uninjured.  I  have  never  seen  harm  result  from 
this  procedure.  If  severe  cystitis  with  decomposition  of  urine  is  pres- 
ent the  bladder  may  be  irrigated  through  the  trocar. 

[To  relieve  urgent  symptoms  of  impermeable  stricture  the  urethra 
may  be  punctured  at  the  apex  of  the  prostate  (Cock's  operation). 

With  the  patient  in  the  lithotomy  position  the  surgeon  introduces 
the  forefinger  of  his  left  hand  into  the  rectum  and  locates  the  apex  of 
the  prostate.  A  sharp  double-edged  knife  is  then  plunged  into  the 
median  line  of  the  perineum  and  carried  toward  the  tip  of  the  finger 
in  the  rectum.  When  the  relation  of  the  parts  are  thoroughly  recog- 
nized and  the  position  of  the  knife  assured  its  tip  is  deflected  a  little 
to  one  side  and  pushed  onward  into  the  urethra.  By  moving  the  knife 
upwards  and  downwards  the  incision  in  the  perineum  is  enlarged;  a 
probe  is  then  carried  into  the  urethra  and  a  catheter  slipped  over  the 
probe. 


STRICTURE    OF    THE    FEMALE    URETHRA.  159 

Mr.  Cock  has  truly  stated,*  "that  however  complicated  may  be  the 
derangement  of  the  perineum,  and  however  extensive  the  obstruction 
of  the  urethra,  one  portion  of  the  canal  behind  the  stricture  is  always 
healthy,  often  dilated,  and  accessible  to  the  knife  of  the  surgeon.  I 
mean  that  portion  of  the  urethra  which  emerges  from  the  apex  of  the 
prostate,  a  part  which  never  is  the  seat  of  stricture,  and  whose  exact 
anatomical  position  may  be  brought  under  the  recognition  of  the 
finger  of  the  operator." 

The  operation,  however,  is  not  so  simple  as  it  appears;  it  should  be 
reserved  for  those  cases  in  which  the  stricture  cannot  be  entered  after 
vesical  puncture  has  been  performed  several  times.  In  urgent  cases, 
in  which  the  general  condition  of  the  patient  is  bad,  it  is  preferable  to 
an  extensive  and  protracted  dissection  of  the  perineum,  as  by  its  per- 
formance the  bladder  can  be  permanently  drained,  and  the  stricture 
treated  later,  after  the  patient's  condition  becomes  improved.] 

As  to  the  question  of  recurrences  it  may  be  said  that  there  is  no 
method  free  from  the  reproach  that  they  may  take  place  after  its  per- 
formance, for,  as  already  stated,  there  can  be  no  cure  of  a  stricture  in 
the  anatomical  sense.  In  general  it  may  be  said  that  the  longer  and 
more  carefully  dilatation  is  carried  out  the  more  lasting  will  be  the 
result ;  no  method  assures  against  relapses  unless  after  treatment  is  given. 
Sounds  must  be  passed  for  a  long  time  after  continuous  dilatation, 
Le  Fort's  procedure,  and  internal  and  external  urethrotomy  in  order 
to  maintain  the  caliber  of  the  urethra,  just  as  after  simple  dilatation. 
In  view  of  these  limitations  the  simplest  method,  namely,  simple  grad- 
ual dilatation,  is  the  method  of  choice.  The  others  are  to  be  em- 
ployed only  when  the  special  indications  above  described  are  present. 
External  urethrotomy  should  be  reserved  for  the  most  difficult  cases, 
as  it  has  the  disadvantage  that  fistulse,  which  are  very  hard  to  close, 
occasionally  remain. 

STRICTURE   OF  THE   FEMALE  URETHRA. 

In  woman  the  occurrence  of  urethral  stricture  is  much  rarer  than  in 
man  and  therefore  of  much  less  importance.  Apart  from  the  very 
rare  congenital  strictures  the  lesion  occurs  mostly  as  the  result  of 
cicatricial  changes  which  occasionally  arise  from  injury.  Difficult 
labor,  either  natural  or  instrumental,  which  wounds  the  urethra,  with- 
drawal of  foreign  bodies  or   calculi  from  the  bladder,    removal   of 

*  Guy's  Hospital  Reports,  1866. 


l6o  DISEASES    OF    THE    URETHRA    AND    PENIS. 

urethral  polypi,  and  severe  chancroidal  ulceration  are  the  causes  of 
this  scar- formation.  I  have  never  seen  any  instances  in  which  chronic 
urethritis  led  to  stricture  as  it  does  in  man. 

The  symptoms  are  always  trivial;  slight  difficulty  in  voiding  urine, 
a  somewhat  longer  duration  of  the  act  than  normally,  and  a  slight 
burning  sensation  are  the  only  symptoms  noticed.  It  is  only  when  com- 
plications, such  as  cystitis,  for  instance,  arise  that  the  symptoms  become 
more  urgent. 

The  diagnosis  is  easily  made  with  a  bougie  a  boule.  Treatment 
consists  in  simple  dilatation  with  bougies.  Only  in  extreme  degrees 
of  constriction  are  one  or  more  incisions  such  as  are  used  in  internal 
urethrotomy  required. 

INJURIES  OF  THE  URETHRA. 

Two  classes  of  injuries  are  recognized:  simple  traumatisms  and  true 
lacerations. 

The  former  may  be  due  to  the  passage  of  foreign  bodies  or  to  the 
improper  introduction  of  an  instrument.  Very  frequently  slight 
injuries  are  sustained  after  crushing  vesical  calculi,  when  a  fragment 
of  stone  remains  in  the  lithotrite  and  the  instrument  is  withdrawn  with- 
out being  entirely  closed. 

The  injuries  due  to  the  introduction  of  catheters  or  bougies  are  gen- 
erally termed  false  passages.  In  the  healthy  urethra  they  seldom 
occur,  although  we  sometimes  see  cases  in  which  fine-pointed  instru- 
ments have  caught  in  the  bulb,  or  entered  one  of  Morgagni's  crypts, 
and  others  in  which  instruments  having  too  short  a  curve  have  gone 
through  the  prostate.  In  a  strictured  urethra  a  false  passage  imme- 
diately in  front  of  the  stricture  is  frequently  made  by  repeated  attempts 
to  pass  an  instrument.  Likewise  false  passages  are  often  seen  around 
an  enlarged  prostate  which  has  twisted  and  distorted  the  urethra; 
the  false  passage  may  go  through  only  a  small  portion  of  the  gland,  or 
perforate  it  in  its  entirety  so  that  the  point  of  the  catheter  reaches  the 
bladder  through  a  channel  tunnelled  through  the  gland. 

It  is  not  always  easy  to  determine  whether  one  has  made  a  false 
passage.  Frequently  the  urethra  gives  way  suddenly  and  the  catheter 
passes  at  once  into  the  bladder.  Generally  some  blood  flows  out  beside 
or  through  the  catheter.  The  pain  caused  by  the  injury  varies  in  inten- 
sity. If  the  instrument  perforates  the  urethral  wall  to  any  extent,  the 
tissue  intervening  between  it  and  the  skin  covering  the  penis  will  be 


INJURIES    OF    THE    URETHRA.  l6l 

felt  as  a  thin  layer.  Micturition  may  not  be  at  all  interfered  with, 
although  if  large  extravasations  of  blood  occur  it  will  become  difficult, 
or  may  be  entirely  arrested;  these  conditions  may  depend  upon  blood- 
clots,  inflammatory  swelling,  or  spasm  of  the  sphincter  occasioned  by 
the  injury.  Not  uncommonly  considerable  constitutional  disturbance 
results;  chills  with  fever  of  days  duration  are  the  rule. 

Treatment  depends  upon  the  existing  conditions.  If  no  stricture 
is  present,  in  the  mildest  cases,  as  for  example  those  caused  by  the 
passage  of  a  stone,  nothing  is  necessary,  as  the  slight  tears  heal  with- 
out treatment.  If  a  false  passage  has  been  made  endeavor  to  pass 
a  soft  catheter,  if  necessary  using  a  staff  as  a  guide,  and  fastening 
the  catheter  into  the  bladder.  If  a  stricture  is  present,  but  the  patient 
able  to  urinate  voluntarily,  refrain  from  further  attempts  to  pass  a 
bougie;  put  the  patient  to  bed  and  give  him  i.o  [15  grains]  of  quinine; 
if  he  cannot  urinate  capillary  puncture  of  the  bladder  may  be  made. 
I  also  advise  its  employment  in  false  passages  around  an  hypertro- 
phied  prostate  (q.  v.).  The  puncture  may  be  performed  several  times, 
after  which  the  patient  generally  can  urinate,  the  false  passage 
having  healed  in  the  meantime.  Large  doses  of  quinine,  1-2.0  [15  to 
30  grains]  a  day,  should  always  be  administered  in  every  injury  of 
the  urethra. 

Lacerations  in  the  penile  portion  of  the  urethra  are  not  very  common. 
They  have  been  observed  as  a  result  of  violent  coitus,  or  an  erection 
during  a  severe  acute  gonorrhoea;  in  the  latter  case  the  swollen  mucous 
membrane  cannot  expand  to  accommodate  itself  to  the  distention  of 
the  penis  produced  by  the  erection,  and  therefore  ruptures.  In  the 
flaccid  condition  of  the  organ  stab- wounds,  blows,  crushes,  and  irri- 
gation of  the  urethra  under  high  pressure  and  without  a  catheter  (after 
the  method  of  Janet)  may  lead  to  lacerations  of  the  mucosa. 

In  the  perineal  portion  of  the  urethra  stabs  and  blows,  but  more 
commonly  a  fall  in  which  the  perineum  strikes  a  hard  object  (the  edge 
of  a  chair,  a  stool,  box  or  plank,  etc.,)  are  responsible  for  lacerations. 
Less  frequently  they  are  due  to  fractures  of  the  pelvis,  a  splinter  of 
bone  piercing  the  urethra. 

Three  degrees  of  laceration  are  recognized ;  in  the  first  there  is  merely 
an  extravasation  of  blood  into  the  corpora  cavernosa,  the  urethral 
mucosa  and  the  outer  fibrous  sheath  of  the  corpora  cavernosa  remain- 
ing uninjured;  in  the  second,  in  addition  to  the  extravasation  of  blood, 
the  urethra  is  torn;  in  the  third  corpora  cavernosa,  urethra,  and  outer 


1 62  DISEASES    OF    THE    URETHRA    AND    PENIS. 

fibrous  envelope  are  all  torn.  In  the  injuries  of  the  posterior  urethra 
lacerations  of  the  second  and  third  degrees  are  the  only  ones  to  be  con- 
sidered. 

Generally  the  tears  occur  immediately  in  front  of  the  triangular 
ligament  (urogenital  diaphragm),  in  the  region  of  the  bulb,  and  most 
commonly  upon  the  under  wall;  the  entire  urethra,  however,  may  be 
torn  through  so  that  the  free  ends  retract  like  a  severed  blood-vessel. 
In  fracture  of  the  pelvis  it  is  usually  the  membranous  urethra  which 
is  involved. 

The  diagnosis  of  these  conditions  is  determined  by  the  three  car- 
dinal symptoms  of  pain,  haemorrhage,  and  disturbance  of  micturition  # 
The  development  of  these  symptoms  are,  however,  entirely  different, 
varying  according  to  the  extent  of  the  injury. 

In  the  mild  cases,  which  we  designate  as  of  the  first  degree,  nothing 
more  than  a  momentary  pain,  followed  by  slight  swelling  of  the  penis 
or  perineum,  may  be  present  to  mark  the  injury.  The  swelling  corre- 
sponds to  the  site  of  the  effusion  of  blood.  These  cases  usually  get  well 
rapidly;  the  effusion  is  resorbed.  and  the  urethra  becomes  perfectly 
free  for  the  passage  of  the  urinary  stream. 

In  cases  of  the  second  degree  urination  is  painful;  as  a  result  of  the 
extravasation  of  blood  the  urine  is  voided  slowly  and  is  mixed  with 
blood,  and  a  distinct  swelling  is  perceptible  over  the  site  of  the  rupture. 

In  the  severe  cases  of  laceration  [those  of  the  third  degree]  serious 
haemorrhages  occur;  they  may  appear  at  the  external  meatus,  or  the 
blood  may  flow  back  into  the  bladder,  or  be  poured  out  through  the 
laceration  and  infiltrate  the  surrounding  tissues.  Even  though  no 
blood  flows  out  of  the  urethra  after  injury  do  not  be  deceived  into  con- 
cluding that  no  laceration  has  taken  place.  The  picture  will  soon 
become  clearer.  The  patient  tries  to  urinate,  but  in  vain;  although 
a  few  drops  may  have  been  voided  at  first,  complete  retention  soon 
develops.  Racked  by  violent  pain  the  patient  strains  in  an  effort  to 
empty  his  bladder,  but  the  only  result  is  increase  in  the  size  of  the 
swelling  in  the  region  of  the  wound,  which  is  usually  in  the  perineum. 
In  case  the  tear  be  in  front  of  the  bulb,  swelling  and  redness  of  the 
penis  and  scrotum  develop.  Here  we  see  the  same  picture  which  we 
drew  when  describing  rupture  of  the  urethra  behind  a  stricture,  that  is, 
infiltration  of  urine  anterior  to  the  bulb.  If  the  wound  lies  behind  the 
urogenital  diaphragm,  then  the  infiltration  extends  toward  the  rectum 
and  bladder. 


INJURIES    OF   THE    URETHRA.  1 63 

This  rapidly  advancing  urinary  infiltration  is  not  always  the  imme- 
diate result.  Nothing  more  may  occur  than  large  accumulations  of 
blood  in  the  region  of  the  laceration,  but  this  is  the  exception.  There- 
fore, if  a  swelling  is  met  with  after  an  injury,  it  is  always  better  to  con- 
sider it  as  an  existing,  beginning,  or  at  least  threatening  infiltration 
originating  from  a  laceration  of  the  urethra  than  as  an  extravasation 
of  blood.  The  case  is  perfectly  plain  if  a  catheter  cannot  be  passed 
into  the  bladder  and  the  urine  withdrawn.  The  tip  of  the  catheter 
goes  only  as  far  as  the  tear,  the  way  into  the  bladder  being  destroyed. 
Constitutional  disturbances,  such  as  chills  and  high  fever,  are  hardly 
ever  absent. 

As  to  treatment,  it  may  be  said  that  in  rupture  within  the  corpora 
cavernosa  (lacerations  of  the  first  degree)  it  will  be  sufficient  to  confine 
the  patient  to  bed,  make  applications  to  the  penis  [lead  water  and 
laudanum  or  dilute  alcohol]  and  give  from  1-2.0  [15  to  30  grains]  of 
urotropin  a  day. 

In  lacerations  of  the  second  degree,  in  which  the  mucous  membrane 
is  also  torn,  it  seems  advisable  to  use  the  catheter  and  to  institute  con- 
tinuous catheterization  as  soon  as  it  can  be  done  without  great  trouble. 
As  the  laceration  is  most  frequently  on  the  under  wall  of  the  urethra, 
care  should  be  taken  to  pass  the  instrument  along  the  upper  wall,  and 
to  use  a  metal  catheter  with  a  pronounced  curve  if  the  urine  is  drawn 
repeatedly,  or  a  similarly  curved  staff  as  a  guide  if  a  retention  catheter 
is  to  be  introduced. 

In  lacerations  of  the  third  degree  catheterization  is  not  appro- 
priate and,  moreover,  could  not  be  successfully  performed  even  if  at- 
tempted, because  the  totally  severed  ends  of  the  urethra  have  retracted 
so  far  from  one  another  that  a  passable  channel  is  no  longer  present. 
An  attempt  may  be  made,  but  only  on  condition  that  the  operation 
shall  not  be  deemed  complete  when  the  catheter  reaches  the  bladder 
and  urine  flows  out;  if  this  be  accomplished  it  is  still  necessary  to  incise 
the  tumefied  tissues  in  order  to  give  free  outlet  to  the  urine  and  its 
decomposition-products. 

It  is  always  best  in  such  cases  to  cut  externally  without  much  attempt 
at  catheterization.  With  the  patient  in  the  lithotomy  position  a  staff  is 
introduced  into  the  anterior  urethra  and  an  incision  made  from  without 
until  the  instrument  appears  in  the  wound.  After  removing  blood  and 
shreds  of  tissue  the  proximal  end  of  the  urethra  is  sought  for;  if  found, 
the  catheter  is  passed  through  it  from  the  distal  end  and  left  in  the 


164  DISEASES    OF    THE    URETHRA    AND    PENIS. 

bladder.     If  practicable  the  two  ends  may  be  sutured  together  over 
the  catheter. 

If  the  proximal  end  cannot  be  found  then  the  only  measure  remain- 
ing is  retrograde  catheterization  (q.  v.).  Upon  the  tip  of  the  instru- 
ment passed  through  the  internal  meatus  a  soft  catheter  is  fastened  and 
drawn  back  into  the  bladder,  and  the  outflow  of  urine  thus  provided  for. 
As  serious  as  these  injuries  at  first  appear,  if  they  are  recognized  and 
treated  in  the  manner  described,  they  are  not  only  not  dangerous  to 
life,  but  almost  always  result  in  complete  recovery.  Failure  to  recog- 
nize, the  condition  may,  of  course,  be  disastrous  to  the  patient; 
enormous  loss  of  substance  which  cannot  be  replaced  may  occur  or 
death  may  be  the  result. 

URINARY  INFILTRATION  AND  URINARY  ABSCESS. 

In  discussing  injuries,  stricture,  and  inflammations  of  the  urethra 
we  had  the  opportunity  of  mentioning  that  these  conditions  may  give 
rise  to  infiltration  of  urine  and  urinary  abscess. 

If  a  larger  tear  occurs  anywhere  in  the  urethra,  and  urine  collects  in 
the  lacerated  parts,  an  infiltration  may  occur  which  is  characterized  by 
diffuse  and  rapid  extension  into  the  surrounding  tissues.  When  the 
lesion  is  small  and  a  few  drops  of  urine  trickle  into  it  during  micturi- 
tion, or  when  there  is  a  circumscribed  inflammation  in  the  neighbor- 
hood of  the  urethra  in  which  a  collection  of  microorganisms  leads  to 
suppuration,  a  urinary  abscess  develops.  If  suppuration  develops 
rapidly  the  condition  is  spoken  of  as  an  acute  abscess;  if  it  develops 
slowly  it  is  known  as  a  cold  or  chronic  abscess.  For  the  develop- 
ment of  urinary  infiltration  it  is  necessary  that  there  be  a  lesion  in 
the  urethra,  but  urinary  abscess  can  occur  without  there  being  any 
break  in  continuity. 

We  observe  infiltration  of  urine,  therefore,  when  a  calculus  in  its 
passage  through  the  urethra,  or  an  instrument,  as  for  example,  the 
lithotrite,  has  produced  an  injury;  or  when,  as  most  frequently 
happens,  the  tissue  behind  a  stricture  has  become  inflamed  and  boggy,  so 
that  the  force  of  the  impinging  stream  of  urine  tears  it. 

We  have  already  carefully  called  attention  to  the  importance  of  de- 
termining whether  the  infiltration  orginates  in  front  of  or  behind  the  uro- 
genital diaphragm.  Fortunately,  in  the  majority  of  cases  it  begins  in 
front  of  this  structure;  less  commonly  it  comes  from  behind,  and  occa- 
sionally from  both  sides.     If  the  infiltration  takes  place  from  the  anterior 


URINARY    INFILTRATION    AND    URINARY    ABSCESS.  1 65 

portion  of  the  urethra,  the  phlegmonous  infiltration  will  advance  from  the 
perineum  to  the  scrotum,  extend  along  the  urethra,  and  work  its  way  to 
the  symphysis  pubis  and  up  the  abdomen;  in  other  cases  phlegmon  of 
the  pelvic  connective  tissue  is  the  result.  The  process  has  a  tendency  to 
advance  towards  the  bladder,  rectum,  and  peritoneum.  The  small 
swellings  which  at  first  arise  grow  quickly  and  assume  an  enormous  size, 
the  skin  reddens,  small  areas  become  gangrenous,  and  if  help  is  not  soon 
rendered  great  loss  of  tissue  occurs;  the  entire  covering  of  the  testicles 
may  be  destroyed;  so  that  these  organs  lie  entirely  unprotected.  Con- 
stitutional phenomena  may  be  absent,  but  generally  high  fever  and 
chills  accompany  the  local  disturbance. 

The  termination  is  usually  favorable  if  early  incision  is  practised, 
although  true  pyaemia  may  develop,  which  is  not  to  be  wondered  at  when 
we  stop  to  consider  that  the  vascular  erectile  tissue  affords  a  specially 
favorable  field  for  the  absorption  of  microorganisms  and  their  delete- 
rious products. 

The  diagnosis  of  infiltration  of  urine  never  presents  difficulties.  The 
only  thing  it  could  be  mistaken  for  is  erysipelas,  and  the  history  of  the 
case,  and  especially  the  circumstance  that  in  erysipelas  great  tumefaction 
is  usually  absent,  should  always  prevent  this  error. 

The  treatment  consists,  as  has  already  been  stated,  in  making  free 
incisions  at  the  earliest  possible  moment.  Wherever  swelling  and  red- 
ness are  present,  from  the  anus  to  high  in  the  abdominal  wall,  the  parts 
must  be  laid  freely  open  and  drained;  the  fever  then  falls  quickly,  the 
gangrenous  tissues  slough  away,  and  the  process  progresses  to  recovery. 
If  a  stricture  caused  the  trouble  it  is  self-evident  that  it  must  be  treated 
(see  Stricture). 

The  conditions  are  different  in  urinary  abscess.  Be  the  cause  what  it 
may,  be  it  that  a  small  lesion  is  present,  or,  that  owing  to  infection  by 
microorganisms  suppuration  develops  in  a  periurethral  focus,  an  abscess 
will  develop  provided  that  the  suppuration  remains  circumscribed  and 
a  limiting  pyogenic  membrane  forms  at  its  periphery  as  a  result  of 
adhesive  inflammation. 

Usually,  even  though  its  onset  be  acute,  it  produces  such  slight  distur- 
bance that  it  is  seldom  noticed  in  the  beginning.  Elevation  of  temper- 
ature, pain,  and  difficult  micturition  are  absent;  it  is  only  when  a  per- 
ceptible tumor  has  formed  that  difficulty  arises.  The  skin  becomes 
red  and  is  sensitive  to  pressure,  and  slight  fever  is  usually  present; 
fluctuation  is  hard  to  detect,  especially  in  the  perineum,  because  the 


1 66  DISEASES    OF    THE    URETHRA    AND    PENIS. 

tense  fascia  prevents  palpation  of  the  deep  tissues.  Left  to  itself  the 
abscess  will  open  either  into  the  urethra  or  externally,  or  perhaps  in 
both  directions;  in  the  latter  case  a  fistula  is  the  inevitable  result. 

The  treatment  consists  in  freely  opening  the  abscess  and  thoroughly 
curetting  it,  so  that  all  its  sinuous  margins  may  be  removed;  it  is  then 
packed  firmly  in  order  that  healing  may  take  place  from  within.  If  the 
wound  is  allowed  to  heal  too  rapidly,  and  without  these  precautions, 
small  fistulae  may  persist. 

Chronic  or  cold  abscesses  differ  from  the  acute  only  in  the  long 
course  of  their  development.  They  are  due  to  the  same  causes,  but 
develop  very  slowly  owing  to  the  circumscribed  character  of  the 
infection. 

Fever,  redness  of  the  skin,  difficulty  of  micturition,  and  pain  are  all 
absent ;  upon  closer  examination  a  small  tumor  is  felt,  which  is  char- 
acterized by  intense  hardness  and  freedom  from  pain,  so  that  one  often 
thinks  he  is  dealing  with  a  solid  tumor.  Rarely  slight  sensations  of 
pain  are  experienced  in  the  urethra.  The  purulent  liquefaction  of  the 
tissues  proceeds  very  slowly  and  is  often  unnoticed.  If  the  abscess 
becomes  connected  with  the  urethra,  a  sudden  profuse  outflow  of  pus 
will  often  take  place  during  or  immediately  after  micturition.  Later, 
however,  the  abscess  also  breaks  externally,  forming  urinary  fistulae  with 
ramifying,  indurated  passages  and  ducts. 

The  treatment  consists  in  laying  the  abscess  widely  open  and  scraping 
it  out  with  the  sharp  curette,  and  also  in  overcoming  the  causative  stric- 
ture or  urethral  inflammation. 

FOREIGN  BODIES  IN  THE  URETHRA. 

There  are  three  ways  in  which  foreign  bodies  can  reach  the  urethra: 
through  the  wall  of  the  penis,  from  the  bladder,  and  through  the  external 
meatus.  The  first  two  are  very  rare.  Foreign  bodies  from  the  bladder 
are  exclusively  stones  or  fragments  of  stones;  they  will  receive  special 
consideration  in  the  next  section.  From  the  exterior  of  the  penis  only 
sharp -pointed  bodies  such  as  needles  can  gain  access  to  the  urethra. 

Because  of  their  rarity  both  these  forms  of  origin  are  of  minor  impor- 
tance in  comparison  with  the  third  form,  in  which  objects  are  introduced 
into  the  urethra  through  the  meatus. 

It  sometimes  happens  that  soft  catheters  or  bougies  break  off  when 
traction  is  made  on  their  external  end,  the  broken  part  remaining  in  the 
urethra.     With  improvement  in  the  quality  of  instruments  these  cases 


FOREIGN    BODIES    IN    THE    URETHRA.  1 67 

will  become  more  rare.  There  remain,  finally,  those  cases  in  which,  gen- 
erally for  the  purpose  of  masturbation,  various  objects,  such  as  needles, 
pins,  hairpins,  sealing-wax,  lead-pencils,  tapers,  fish-bones,  horse-hairs, 
etc.,  are  introduced.  The  outer  end  of  these  objects  suddenly  escapes 
from  the  fingers  and  cannot  be  caught  again.  They  wander  into  the 
urethra  and  may  proceed  against  the  urinary  stream  into  the  bladder; 
they  may  also  remain  at  their  original  site.  Generally  they  are  found  in 
the  widest  portions  of  the  canal,  that  is,  the  fossa  navicularis  and  the  bulb. 
The  changes  which  they  undergo  depend  upon  their  nature :  they  swell  or 
become  incrusted  with  urinary  salts,  or  if  soft  become  bent  into  the  shape 
of  the  urethra. 

Symptoms.  Upon  the  entrance  of  a  foreign  body  into  the  urethra 
pain,  varying  with  the  nature  of  the  object,  is  generally  experienced ;  it  is 
usually  intensified  when  the  position  of  the  penis  is  changed,  when  erec- 
tions occur,  or  when  manipulations  are  made  for  the  purpose  of  locating 
or  removing  the  foreign  body.  Haemorrhage  may  be  present  or  absent. 
Disturbances  of  urination  occur  only  when  the  urethra  is  considerably 
obstructed;  when  this  condition  is  present  micturition  is  painful.  The 
stream  is  small  and  interrupted;  at  times  complete  retention  of  urine 
develops,,  being  due  either  to  complete  occlusion  of  the  passage,  or  to 
spasm  of  the  external  sphincter  produced  by  irritation. 

If  the  foreign  body  remains  in  the  urethra  for  any  length  of  time,  a 
sero-purulent  or  sanguinolent  discharge,  similar  to  that  seen  after  a  cath- 
eter has  been  retained  for  a  considerable  period,  is  wont  to  appear. 
Therefore,  the  first  portion  of  the  urine  is  turbid.  If  the  inflammatory 
process  extends  to  the  bladder,  as  it  usually  does  unless  the  object  is 
removed  within  a  few  days,  the  urine  shows  evidence  of  the.  presence  of 
cystitis,  being  also  cloudy  in  its  second  portion.  Fever  need  not  be  pre- 
sent. Cases  have  been  observed  in  which  foreign  bodies  have  remained 
in  the  urethra  for  years  without  causing  disturbance  of  the  general 
health.  Only  when  infection  occurs  simultaneously  with  the  injury  do 
the  manifestions  of  fever  arise.  Under  these  latter  circumstances  a  local 
inflammatory  process  is  evolved,  which  at  first  is  characterized  by  severe 
oedema,  extending  perhaps  from  the  site  of  the  foreign  body  to  the 
meatus,  and  which  later  assumes  the  form  of  a  circumscribed  phlegmon , 
slowly  spreading  more  and  more  until  it  possesses  all  the  characteristics 
of  a  urinary  infiltration.  In  these  cases  the  urine  gains  access  to  the 
damaged  parts,  and,  owing  to  the  decomposition  which  it  undergoes, 
causes  the  disturbances  just  described.     If  the  phlegmon  remains  cir- 


1 68  DISEASES    OF    THE    URETHRA    AND    PENIS. 

cumscribed   a  urinary  abscess  develops,  from  which  a  fistula  nearly 
always  results. 

Diagnosis.  From  the  description  of  the  symptoms  it  is  evident  that 
the  diagnosis  can  offer  hardly  any  difficulties,  although  cognizance  must 
be  taken  of  the  fact  that  patients,  because  of  shame,  are  inclined  to  con- 
ceal the  real  state  of  affairs.  Palpation  will  reveal  the  location  of  the 
foreign  body.  It  can  be  felt  in  the  movable  part  of  the  urethra  through 
the  perineum,  [along  the  under  surface  of  the  penis  when  in  the 
penile  portion],  and  in  the  membranous  portion  through  the  rectum.  If 
a  sound  or  catheter  be  employed  to  confirm  its  location  care  should  be 
taken  to  compress  the  urethra  behind  the  foreign  body  with  the  finger, 
so  as  not  to  force  the  body  further  back.  Occasionally  the  object  can  be 
seen  with  the  urethroscope. 


S— $=;; 


Fig.  148. — Urethral  forceps  of  Collin  (a),  Leroy  d'Etiolles  {b), 
and  Hunter  (c). 

Treatment.  The  first  thing  to  do  is  to  remove  the  foreign  body  from 
the  urethra.  Very  rarely  spontaneous  expulsion  occurs,  but  generally 
the  object  is  so  firmly  impacted  against  the  wall  of  the  urethra  that 
spontaneous  expulsion  by  the  force  of  the  urine  is  not  to  be  counted  upon. 
Therefore  an  attempt  should  be  made  to  seize  and  remove  it  through 
the  urethra.  For  this  purpose  foreign-body  forceps,  of  which  many  have 
been  designed,  are  employed.  We  will  mention  only  those  of  Hunter, 
Leroy  d  'Etiolles,  and  Collin  (Fig.  148),  of  which  the  last  two  are  the  best. 
The  instrument  of  Leroy  d  'Etiolles  is  provided  with  a  joint.  It  is  in- 
troduced extended,  so  that  the  lever  may  pass  behind  the  foreign  body; 
the  joint  is  then  turned  to  a  right  angle  with  the  shaft  and  an  effort 
made  to  draw  the  object  out  of  the  urethra.  For  the  removal  of 
broken  off  sounds  and  catheters  Hunter's  or  Collin's  forceps  are  better. 


FOREIGN    BODIES    IN    THE    URETHRA.  1 69 

They  are  introduced  closed  and  are  opened  as  soon  as  the  foreign  body 
is  reached.  The  catheter  is  prevented  from  being  pushed  into  the 
bladder  by  pressing  on  the  urethra  behind  it  with  the  left  hand. 

If  neither  of  the  above  methods  prove  successful  two  alternatives  re- 
main :  the  urethra  may  be  opened  at  the  place  where  the  foreign  body  lies, 
the  body  extracted,  and  the  urethra  sutured  if  there  be  no  abscess  nor 
infiltration  of  urine,  and  drained  in  case  either  of  these  two  conditions 
be  present;  or  the  foreign  body  may  be  pushed  back  into  the  bladder, 
exposed  to  view  with  the  cystoscpe,  and  extracted  by  means  of  the  cysto- 
scopic  forceps.  The  latter  procedure  is  to  be  employed  in  all  cases  in 
which  the  foreign  body  is  not  firmly  wedged  into  the  urethra.  With 
a  little  practice  catheters,  bougies,  tapers,  and  pieces  of  sealing-wax  can 
easily  be  removed  from  the  bladder.  I  have  often  done  this  with 
success. 

When  the  object  cannot  be  pushed  backward  without  difficulty, 
incision  is  preferable,  because  if  force  be  employed  to  move  the  foreign 
body  the  urethra  will  be  injured. 

URETHRAL    CALCULI. 

Urethral  calculi  occur  almost  exclusively  in  the  male  sex.  With  few 
exceptions  their  presence  is  due  to  the  fact  that  calculi  or  fragments  of 
calculi  from  the  upper  urinary  tract  reach  the  urethra  and  remain  there. 

The  rare  exceptions  in  which  a  stone  forms  in  the  urethra  happen 
when  a  urinary  fistula  exists,  or  when  a  small  foreign  body  is  retained 
for  a  long  time.  The  latter  are  not  true  calculi,  but  rather  incrusted 
foreign  bodies.  In  fistula;  urinary  crystals  are  occasionally  deposited 
around  a  nucleus  of  inspissated  pus. 

In  most  cases  we  have  to  deal  with  vesical  or  renal  stones  which  have 
been  forced  into  the  urethra.  The  latter,  unless  they  have  remained 
some  time  in  the  bladder,  are  characterized  by  their  regular  form,  while 
the  former  are  of  different  shapes.  If  they  remain  long  in  the  urethra 
they  undergo  still  further  changes  in  form  owing  to  the  deposition  of 
urinary  salts  upon  their  surface.  The  portion  of  the  urethra  in  which 
they  lie  also  exerts  an  influence  upon  their  form;  thus,  when  in  the  pos- 
terior urethra  they  become  larger  because  this  portion  is  more  dilatable. 

When  a  stone  gets  into  the  urethra  it  generally  lodges  in  some  narrow 
portion  of  the  canal,  being  found  most  frequently  just  behind  the 
meatus,  and  next  in  the  beginning  of  the  membranous  portion.     If  a 


170  DISEASES    OF    THE    URETHRA    AND    PENIS. 

stricture  is  present  the  stone  usually  lies  behind  it.  It  is  evident  that 
strictures  furnish  the  most  common  cause  for  the  retention  of  calculi  in 
the  urethra. 

The  so-called  pipe-stones,  part  of  which  lie  in  the  urethra  and 
part  in  the  bladder,  must  also  be  considered  as  urethral  calculi.  The 
two  portions  of  the  stone  form  an  angle  with  one  another  similar  to  the 
two  pieces  of  a  pipe-head. 

Those  prostatic  calculi  the  free  end  of  which  projects  into  the  urethra 
also  come  under  the  head  of  urethral  calculi.  Those  which  are  entirely 
surrounded  by  prostatic  tissue  are,  of  course,  known  as  prostatic  calculi. 
The  existence  of  prostato-urethral  calculi  has  been  denied  by  many,  but 
I  have  observed  several  such  cases,  one  of  which  was  seen  post- 
mortem, the  end  of  a  stone  projecting  from  a  pocket  in  the  prostate, 
while  the  body  was  firmly  held  within  the  pocket. 

The  symptoms  of  urethral  calculi  vary  according  to  their  nature  and 
location  and  their  manner  of  entry  intothe  urethra. 

If  a  stone  suddenly  comes  into  the  urethra,  pain  is  usually  experienced 
at  the  place  where  the  stone  is  arrested;  if  it  happens  during  micturi- 
tion the  stream  may  be  suddenly  interrupted,  or  at  least  considerably 
checked,  and  a  few  drops  of  blood  may  escape  with  the  urine.  The 
dysuria  lasts  as  long  as  the  stone  remains,  and  can  lead  to  complete 
retention  of  urine.  If  it  lies  far  back,  near  the  neck  of  the  bladder, 
slight  incontinence  is  not  infrequently  present. 

In  other  cases  the  stone  gets  into  the  urethra  without  attracting  the 
patient's  attention.  As  it  increases  in  size  dysuria,  which  may  or  may 
not  be  accompanied  by  pain,  develops.  Thus  the  stone  may  remain  in 
the  urethra  a  long  time  without  giving  rise  to  any  alarming  symptoms. 
Occasionally  the  area  occupied  by  the  stone  becomes  inflamed,  and  the 
inflammation  may  advance  to  ulceration,  as  a  result  of  which  urinary 
abscess  or  deep-seated  phlegmon  may  form,  or  urinary  infiltration  may 
be  produced. 

This,  however,  is  not  the  rule,  the  urethra  generally  being  very  toler- 
ant to  calculi,  which  may  remain  for  months  or  even  years  without  caus- 
ing trouble.  The  results  then  are  merely  a  gradual  dilatation  behind 
the  stone,  with  inflammation  of  the  dilated  portion  and  extension  of  the 
suppurative  process  to  the  bladder.  If  its  course  be  chronic  fever  is 
absent;  if  acute  it  is  present.  I  have  often  known  urethral  calculi 
to  fall  back  into  the  bladder  and  then  be  carried  into  the  urethra  again 
by  the  urinary  stream. 


FOREIGN    BODIES    IN   THE    URETHRA.  171 

The  diagnosis  of  urethral  calculi  seldom  presents  difficulties.  The 
symptoms  enumerated  point  to  the  presence  of  a  stone,  and  palpation 
and  sounding  enable  us  positively  to  determine  its  existence.  Palpation 
of  the  urethra  along  the  penis  and  in  the  perineum,  as  well  as  through 
the  rectum,  may  deceive  us  insofar  as  other  indurations  may  be  mis- 
taken for  calculi;  for  this  reason  examination  with  the  sound, preferably 
a  metal  instrument,  should  not  be  omitted.  If  a  stricture  is  not  in 
front  of  the  calculus,  a  distinct  grating  will  be  felt  as  soon  as  the  metal 
comes  in  contact  with  the  stone. 

The  situation  is  more  difficult  when  a  stricture  is  present  and  the  cal- 
culus lodges  behind  it,  for  then  only  slender  soft  instruments  can  be  in- 
troduced, and  the  friction  which  is  produced  by  their  contact  with  the 
rough  surface  of  the  stone  is  very  similar  to  that  experienced  in  sounding 
indurated  strictures.  Accurate  diagnosis  can  be  readily  made,  however, 
if  the  stricture  be  at  once  dilated  or  cut,  or  if  an  X-ray  picture  be  taken, 
the  latter  procedure,  of  course,  being  employed  only  when  the  stone 
does  not  lie  beyond  the  bulb  of  the  urethra. 

As  to  treatment  it  is  well  to  distinguish  between  calculi  of  the 
anterior  and  posterior  urethra. 

Those  in  the  anterior  urethra  can  be  removed  either  through  the 
natural  passage  or  by  means  of  urethrotomy;  in  the  first  method  the 
urethral  forceps,  which  have  been  described  in  considering  the  treatment 
of  foreign  bodies,  are  employed  (see  page  168). 

If  a  stricture  is  present  it  must  be  overcome  before  extraction  through 
the  meatus  can  be  accomplished.  If  the  stone  is  near  the  opening 
meatotomy  is  performed;  if  it  is  further  back  recourse  is  had  to 
internal  urethrotomy  as  soon  as  a  guide  can  be  passed  by  it  into  the 
bladder.  If  this  cannot  be  done,  if  internal  urethrotomy  is  not  prac- 
ticable, or  if  urinary  fever  supervenes,  showing  that  infection  has  taken 
place,  then  I  advise  external  urethrotomy.  In  absence  of  inflammation 
and  infection  the  wound  may  be  entirely  closed;  otherwise  nothing 
but  the  urethra  is  closed,  and  even  it  may  be  left  open.  Two  methods 
are  used  for  removing  stones  in  the  posterior  urethra:  the  calculus  is 
either  pushed  back  into  the  bladder  and  crushed,  or  it  is  extracted  by 
means  of  an  external  urethrotomy.  The  first  procedure  is  the  simpler 
and  less  dangerous,  and  should  always  be  chosen  when  the  stone  is 
movable  and  can  be  easily  carried  back  into  the  bladder.  Whenever 
this  cannot  be  done  without  difficulty,  and  there  is  danger  of  wounding 
the  urethra,  urethrotomy  is  to  be  preferred. 


172  DISEASES    OF    THE    URETHRA    AND    PENIS. 

Lithotripsy  either  in  the  anterior  or  posterior  urethra  should  not  be 
practised. 

Urethral  calculi  in  the  female  are  very  rarely  observed.  Their  de- 
velopment is  due  to  bulging  of  the  mucous  membrane,  as  the  result  of 
which  a  pocket  or  diverticulum  is  formed,  which  is  known  as  a  urethro- 
cele, and  in  which  the  urine  may  collect  and  decompose  and  its  salts  give 
rise  to  the  formation  of  calculi. 

The  symptoms  consist  of  more  or  less  pain  upon  urination,  especially 
at  the  beginning  of  the  act,  dysuria,  incontinence,  and  an  uncomfort- 
able feeling  when  the  patient  is  sitting.  Palpation  reveals  a  swelling 
which  is  hard,  and  the  nature  of  which  is  at  once  manifested  by  the 
crepitation  which  is  elicited. 

Sometimes  the  stone  can  be  extracted  from  the  pocket.  If  recur- 
rences take  place  it  is  advisable  to  excise  the  urethrocele  and  suture 
the  urethral  wound. 

TUMORS  OF  THE  URETHRA. 

TUMORS  OF  THE  MALE  URETHRA. 

Tumors  of  the  urethra  are  very  uncommon  in  man.  Polypous  or 
papillomatous  growths,  malignant  tumors  (carcinomata),  cysts,  and 
angiomata  are  met  with,  occurring  as  to  frequency  in  the  order  men- 
tioned. 

The  polypi  and  papillomata  are  histologically  the  same  as  condy- 
lomata. They  are  rarely  solitary,  several  occurring  together  in  the  same 
urethra.  Their  site  of  predilection  is  the  region  of  the  external  meatus, 
although  they  may  occur  anywhere  in  the  urethra  as  far  back  as  the 
neck  of  the  bladder. 

Their  development  is  to  be  attributed  to  the  same  causes  which  pro- 
duce condylomata  on  the  glans  penis.  We  know  that  condylomata 
develop  not  only  as  the  result  of  gonorrhceal  infection,  but  frequently  as 
an  accompaniment  of  balanitis.  The  same  irritation  which  brings 
about  their  development  on  the  exterior  of  the  penis  may  be  considered 
responsible  for  their  occurrence  in  the  urethra. 

The  symptoms  which  they  make  are  of  a  very  trifling  character. 
Generally  they  keep  up  a  slight  serous  or  sero-purulent  discharge,  which 
is  usually  regarded  as  a  sequel  of  gleet.  If  their  number  become 
greater  and  they  extend  nearer  to  the  neck  of  the  bladder,  they  may 


TUMORS    OF    THE    URETHRA.  1 73 

perhaps  give  rise  to  phenomena  resembling  those  caused  by  stricture. 
Occasionally  they  may  cause  slight  urethral  haemorrhage. 

The  diagnosis,  however,  cannot  be  made  from  these  manifestations, 
but  requires  the  use  of  the  urethroscope.  If  a  small  wart  is  seen  at  the 
meatus  and  signs  of  a  chronic  urethral  discharge  persist,  then  the  sus- 
picion that  other  growths  are  present  further  back  in  the  urethra  is 
justifiable. 

Treatment  is  most  simple.  The  tumors  growing  near  the  meatus 
are  snipped  off  with  scissors,  and  those  deeper  down  in  the  urethra  are 
removed  through  the  urethroscope  with  a  tampon-holder,  a  curette, 
or  the  galvano-cautery. 

Carcinoma  of  the  urethra  may  be  primary  or  secondary.  The  for- 
mer is  of  very  rare  occurrence,  the  growth  usually  being  due  to  extension 
of  a  cancer  from  the  rectum  or  prostate.  In  the  cases  of  primary  car- 
cinoma observed  stricture  or  fistula  of  the  urethra  was  always  present,  so 
that  a  causative  relation  must  be  attributed  to  them. 

In  its  early  stages  urethral  cancer  presents  no  characteristic  signs.  It 
may  cause  interference  with  micturition,  thus  simulating  stricture ;  occa- 
sionally, too,  slight  pain  and  haemorrhage  occur,  which  may  likewise  be 
referred  to  stricture.  It  is  only  when  the  disease  is  further  advanced 
that  it  becomes  recognizable  by  the  presence  of  a  palpable  tumor, 
dysuria,  painful  micturition,  swelling  of  the  inguinal  glands,  and  general 
decline.  Strong  suspicion  of  a  malignant  growth  in  the  urethra  should 
be  entertained  when  an  irregular  hard  tumor,  or  even  fistula?,  develop 
irrespective  of  the  usual  causes,  namely,  gonorrhoea  and  stricture. 

Unfortunately,  in  the  stage  in  which  the  disease  is  recognized  it  is 
usually  too  late  for  treatment.  It  consists  in  total  removal  of  the  tumor, 
together  with  the  surrounding  parts  of  the  urethra.  Resection  of  the 
urethra  has  been  done  with  good  results  in  cases  in  which  the  growth 
was  situated  in  the  posterior  urethra;  when  in  the  anterior  portion 
amputation  of  the  penis  is  the  only  proper  procedure. 

Cysts  of  the  urethra  are  to  be  considered  as  retention  cysts  due  to 
occlusion  of  urethral  glands.  They  may  develop  from  the  mucous 
glands,  but  generally  arise  from  the  glands  of  Cowper.  The  latter 
form  has  been  studied  by  English. 

Only  a  single  case  of  echinococcus  cyst  has  been  reported,  and  that 
one  was  observed  by  Pean. 

As  a  curiosity  it  may  be  mentioned  that  a  few  cases  of  angioma  of 
the  urethra  have  been  observed. 


174  DISEASES    OF    THE    URETHRA    AND    PENIS. 

TUMORS    OF    THE    FEMALE    URETHRA. 

Tumors  of  the  female  urethra  are  much  more  common  than  those  of 
the  male.  The  following  varieties  are  found :  papilloma  or  condyloma, 
angioma,  cysts,  fibroma,  sarcoma  and  carcinoma,  elephantiasis,  and, 
lastly,  prolapse  of  the  urethral  mucous  membrane  simulating  a  tumor. 

The  papillomata  occur  usually  in  the  form  of  condylomata  around 
the  urethral  orifice.  They  cause  neither  pain  nor  inconvenience,  and  as 
a  rule  do  not  bleed.  A  conglomeration  of  these  growths  may  be  mis- 
taken for  a  cauliflower-like  tumor. 

The  angiomata,  fungous  excrescences  sometimes  known  as  urethral 
caruncle,  represent  areas  of  thickened  mucous  membrane  in  which 
there  is  an  abnormal  development  of  veins.  They  might  rightly  be  called 
varices  or  hemorrhoids  of  the  urethra.  They  are  usually  on  the  under 
wall  near  the  meatus,  and  may  attain  the  size  of  a  raspberry.  Any 
influence  leading  to  congestion  (standing  for  a  long  time,  straining, 
menstruation)  causes  them  to  swell,  and  if  a  varix  results  therefrom 
true  haematoma  may  develop. 

The  cysts  of  the  female  urethra  are  also  retention  cysts  which  develop 
from  the  glandular  elements.  If  they  project  sharply  from  the  mucous 
membrane  a  pedicle  is  formed,  and  they  are  then  known  as  mucous 
polypi,  for  the  reason  that  their  walls  consist  solely  of  mucous  mem- 
brane. 

Fibromata,  which  are  solid  tumors,  also  occurring  in  the  form  of 
polypi,  are  very  rare,  as  are  also  sarcomata  and  primary  carcino- 
mata.  Of  more  frequent  occurrence  are  cancerous  growths  due  to  ex- 
tension of  disease  from  neighboring  organs  (vagina,  clitoris). 

Elephantiasis  occurs  with  the  greatest  rarity.  A  case  has  been 
recorded  in  which  elephantiasis  of  the  vulva  invaded  the  urethra  and 
destroyed  it. 

In  general  the  symptoms  caused  by  these  various  kinds  of  tumors 
depend  upon  their  size  and  location.  They  frequently  produce  signs 
of  irritation  and  itching,  but  they  may  not  cause  any  symptoms  whatever. 
If  they  obstruct  the  lumen  of  the  urethra  dysuria  results.  Dribbling  of 
urine  is  observed  if  the  internal  meatus  is  separated  by  a  tumor.  Haem- 
orrhage may  occur  or  be  absent.  Oftentimes  the  condition  is  discovered 
accidentally  when  an  examination  is  being  made  for  another  purpose. 

With  the.  exception  of  the  malignant  growths,  which  are  often  charac- 
terized by  rapid  ulceration,  these  tumors  may  remain  unchanged  for 
years. 


TUMORS    OF    THE    URETHRA.  1 75 

Treatment  consists  in  removal  of  the  tumor.  The  manner  in  which 
this  is  done  varies  according  to  the  nature  of  the  growth.  Pedunculated 
benign  excrescences  can  be  removed  with  the  cold  or  galvano-caustic 
snare,  or  with  the  scissors,  and  the  base  then  cauterized.  More  exten- 
sive tumors  are  better  excised  with  the  knife,  so  that  the  incision  can  be 
carried  into  healthy  tissue  and  made  in  the  long  axis  of  the  urethra.  The 
cut  surfaces  are  sutured.  Small  multiple  growths  can  be  satisfactorily 
treated  with  the  thermocautery. 

The  malignant  growths  require  not  only  extirpation,  but  also,  if  pos- 
sible, removal  of  the  primary  focus  of  disease. 

Urethrocele  (Prolapse  of  the  Female  Urethra). 

Prolapse  of  the  urethra,  which  sometimes  assumes  the  form  of  a  tumor, 
may  easily  be  confounded  with  the  new  growths  above  described. 
When  of  slight  degree  they  present  the  appearance  of  labiated  elevations, 
between  which  the  urethral  orifice  is  included.  Their  cause  is  to  be 
found  in  a  relaxed  condition  of  the  urethra  and  vagina,  such  as  may  be 
produced  by  quickly,  repeated  labors,  rapid  dilatation  of  the  urethra  by 
foreign  bodies,  the  passage  of  calculi,  masturbation,  etc.  If  the  subject 
of  this  slight  prolapse  is  exposed  to  any  strain,  as  for  instance  that 
necessitated  at  stool  by  constipation  of  the  bowels,  or  that  caused  by 
strangury,  the  small  protrusion  of  the  urethra  may  be  converted  into  a 
large  tumor  the  size  of  a  pigeon's  egg,  which  may  totally  obliterate  the 
view  of  the  urethral  orifice. 

In  the  early  stages,  when  the  protrusion  is  slight,  its  possessor  experi- 
ences practically  no  difficulty,  and  may  not  even  know  that  an  abnormal 
condition  is  present.  If  it  increases  in  size  painful  and  difficult 
micturition,  as  well  as  haemorrhage  and  incontinence  of  urine,  may 
ensue,  and  the  urethra  become  inflamed  and  eroded. 

Upon  careful  inspection,  especially  if  the  suspected  growth  be  lifted 
up  with  forceps,  it  will  be  almost  always  recognized  that  the  supposed 
tumor  is  only  an  extroversion  of  the  urethral  walls. 

The  smaller  protrusions  may  be  destroyed  with  the  Paquelin  cautery ; 
the  larger  ones  require  removal  by  the  knife,  the  edge  of  the  wound  in  the 
mucous  membrane  being  sutured. 

TUBERCULOSIS    OF    THE    URETHRA. 

Tuberculosis  of  the  male  urethra  is  an  exceptionally  uncommon  dis- 
ease and  is  always  secondary.     According  to  my  observations  it  occurs 


176  DISEASES    OF    THE    URETHRA    AND    PENIS. 

only  in  association  with  tuberculosis  of  the  bladder,  prostate,  and 
seminal  vesicles.  It  is  therefore  exclusively  confined  to  the  posterior 
urethra. 

Primary  tuberculosis  of  the  female  urethra  is  also  unknown,  the 
disease  invariably  extending  from  contiguous  organs,  especially  the 
bladder. 

If  lupus  be  considered  as  true  tuberculosis,  then  it  is  to  be  stated  that 
lupus  nodules  may  extend  from  the  vagina  to  the  urethra  and  infiltrate 
its  walls,  as  the  result  of  which  narrowing  is  produced,  or  the  nodules 
may  coalesce  on  the  surface  of  the  urethra  and  form  a  true  ulceration  of 
the  mucosa. 

MALFORMATIONS  OF  THE  URETHRA. 

I.    ABSENCE    OF    THE  URETHRA. 

This  malformation  is  exceedingly  rare.  One  case  of  total  absence 
and  another  of  partial  absence  have  been  reported ;  in  the  first  the  patient 
urinated  through  the  anus,  in  the  second  through  an  opening  anterior  to 
the  anus.     The  penis  was  absent. 

2.  COMPLETE  AND  PARTIAL  OBLITERATION  OF  THE  URETHRA. 

Obliteration  of  the  urethra  is  a  form  of  arrested  development  due  to 
unequal  growth  of  the  three  parts  out  of  which  the  male  urethra  is 
formed. 

In  partial  obliteration  there  is  so  much  narrowing  at  the  external 
meatus  that  a  needle  can  hardly  be  passed  into  the  urethra.  This  ab- 
normality naturally  leads  to  severe  disturbances  unless  immediate  relief 
is  given  by  the  operation  of  meatotomy. 

In  complete  obliteration  either  the  skin  or  the  urethral  mucous  mem- 
brane forms  the  occlusion,  or  the  entire  urethra  is  converted  into  a  firm 
cord.  Occlusion  of  the  skin  reaches  only  a  short  distance  into  the 
urethra,  that  of  the  mucous  membrane  may  extend  further  back;  the 
cord-like  transformation  generally  extends  far  back,  and  is  almost  always 
associated  with  occlusion  of  the  anus.  Unless  an  opening  for  the  exit  of 
urine  is  at  once  made,  or  unless  its  exit  is  provided  for  in  some  other  way, 
as  for  example,  by  communication  of  the  ureters  with  the  rectum,  or  the 
bladder  with  an  open  urachus,  the  child  will  soon  die. 

3.    DOUBLE    URETHRA. 

Various  malformations  have  been  described  as  double  urethra  which 
in  reality  are  only  accessory  blind  fissures  or  congenital  fistulse  of  the 


MALFORMATIONS    OF    THE    URETHRA.  1 77 

penis.  These  fissures  are  lined  with  mucous  membrane  and  are  fre^ 
quently  the  seat  of  disease,  for  instance,  gonorrhoea.  Very  often  such 
blind  pockets  are  found  near  the  external  meatus,  although  they  also 
occur  in  the  deep  urethra,  and  are  to  be  regarded  as  cysts  or  dilatations 
of  the  crypts  of  Morgagni.  True  double  urethra  occurs  only  when  a 
double  penis  is  present. 

4.    URETHRAL  DIVERTICULUM. 

Localized  expansion  of  the  urethra  may  occur  behind  a  construction 
situated  far  forward  or  may  be  due  to  an  increase  in  size  of  the  normal 
crypts  and  duplicatures  of  the  urethra.  Such  pockets,  funiculi,  and 
valves  can  occasionally  be  seen  near  the  meatus  or  brought  into  view 
by  means  of  the  urethroscope  when  they  are  situated  further  back  in  the 
urethra.     If  they  cause  trouble  they  must  be  divided. 

5.    ABNORMAL  COMMUNICATION  OF  THE  URETHRA  WITH  THE 
URETERS  AND  RECTUM. 

Both  of  these  malformations  are  very  rare.  Opening  of  the  ureters 
directly  into  the  urethra  has  been  observed  in  cases  of  total  or  partial 
absence  of  the  bladder,  and  communication  between  the  rectum  and 
urethra  has  been  seen  in  cases  of  imperforate  anus. 

6.    FISSURES  OF  THE  URETHRA. 

(a)  Hypospadias.  By  hypospadias  is  meant  a  malformation  in 
which  the  urethra  does  not  open  on  the  glans,  but  on  the  under  side  of 
the  penis.  If  the  cleft  lies  immediately  behind  the  glans  it  is  known  as 
hypospadias  glandis,  if  on  the  shaft  of  the  penis  as  hypospadias  penis, 
and  if  the  scrotum  is  also  cleft  and  the  opening  of  the  urethra  is  in  the 
perineum  it  is  spoken  of  as  hypospadias  perinealis. 

The  origin  of  this  malformation  may  be  explained  by  the  following 
circumstances.  The  urethra  is  formed  out  of  three  elements :  the  gland- 
ular portion  is  an  invagination  of  the  corneal  layer,  and  grows  toward  the 
primary  urethra  just  as  the  anus  grows  toward  the  rectum;  the  middle 
portion  develops  from  the  sinus  urogenitalis;  the  third  is  of  primary 
origin.  In  explanation  of  the  various  degrees  of  hypospadias  it  may  be 
assumed  that  one  or  the  other  of  these  portions  undergoes  an  arrest  of 
development.  The  condition  is  almost  always  associated  with  abnor- 
malities of  the  penis. 

In  hypospadias  glandis  (Fig.  14Q,)  the  penis  is  generally  short  and 
curved  downward;  not  uncommonly  it  bends  downward  when  turgid 


178  DISEASES    OF    THE    URETHRA    AND    PENIS. 

instead  of  becoming  erect  like  the  normal  penis.     Where  the  urethral 
orifice  is  found  normally  there  is  often  a  small  hole,  which  is  continued 


Fig.  149. — Hypospadia  glandis. 


Fig.  150. — Hypospadia  penis. — (Duplay). 

backward  as  a  groove  and  ends  where  the  real  urethral  opening  begins. 
From  the  latter  point  a  slender  bougie  can  be  passed  into  the  bladder. 


MALFORMATIONS    OF    THE    URETHRA. 


179 


In  hypospadias  penis  the  urethral  opening  lies  between  the  corona 
glandis  and  the  scrotum.  From  the  orifice  a  furrow  usually  extends 
anteriorly,  the  mucous  membrane  being  continued  in  it  (Fig.  150). 

Hypospadias  perinealis,  the  third  degree  of  urethral  fissure,  in  which  a 
deep  sulcus  divides  the  scrotum  and  perineum  into  two  parts,  is  very 
rarely  encountered.  The  urethral  opening  lies  in  the  depth  of  this  fissure 
behind  the  scrotum .     In  front  of  it  a  furrow  extends  anteriorly  (Fig.  151). 

In  all  three  cases  there  may  be  a  second  opening  into  the  urethra  in 


Fig.  151. — Hypospadia  perinealis. 

front  of  the  true  orifice,  the  former  ending  in  a  blind  canal,  which  is  a 
portion  of  the  urethra  that  has  not  united  with  the  part  posterior  to  it. 

Hypospadias  also  occurs  in  the  female,  a  greater  or  less  portion  of  the 
under  wall  of  the  urethra  being  replaced  by  a  furrow. 

In  its  milder  degrees  hypospadias  does  not  generally  cause  any  symp- 
toms. It  is  only  when  the  opening  is  exceedingly  narrow  that  symptoms 
similar  to  those  produced  by  stricture  appear.  The  downward  curvature 
of  the  penis  may  interfere  with  cohabitation.  In  general  the  subjects  of 
hypospadias  of  the  first  degree  possess  the  potentia  cceundi  and  also  the 
potentia  generandi.     In  hypospadias  peno-scrotalis  and  perinealis  coitus 


l8o  DISEASES    OF    THE    URETHRA    AND    PENIS. 

is  impossible,  and  the  unavoidable  wetting  of  the  soft  parts  in  the  area 
around  the  urethral  orifice  is  most  annoying. 

The  treatment  of  hypospadias  is  operative  whenever  one  or  more 
of  the  symptoms  described  necessitate  treatment.  In  the  milder 
degrees  it  is  usually  unnecessary  to  do  anything. 

If  an  enlargement  of  the  external  orifice  is  required,  meatotomy  is  per- 
formed by  making  an  incision  along  the  under  wall  of  the  urethra;  the 
skin  and  mucous  membrane  are  then  sewed  together  on  either  side. 

If  such  a  shortening  of  the  penis  exists  as  to  cause  it  to  curve  markedly 
downward  during  erection,  the  organ  must  be  straightened  by  making  a 
moderately  deep  transverse  incision  severing  the  connecting  strand  be- 
tween the  scrotum  and  under  surface  of  the  penis,  and  then  suturing  the 
wound  lengthwise. 

If  it  is  necessary  to  establish  a  new  urethral  opening  situated  more 
anteriorly,  and  the  absent  segment  of  the  urethra  is  not  too  great,  a  large 
trocar  may  be  plunged  from  the  glans  through  the  penis  in  such  a  man- 
ner that  its  point  shall  come  out  through  the  true  urethral  orifice. 
Through  the  newly  formed  canal  a  soft  catheter  is  passed  into  the  blad- 
der and  fastened  in  place;  the  edges  of  the  wound  are  then  freshened  and 
sewed  over  the  catheter. 

In  the  more  severe  grades  of  hypospadias  Duplay's  procedure  should 
be  employed.  It  consists  of  three  separate  operations:  i.  straighten- 
ing of  the  penis  and  establishment  of  an  external  orifice ;  2.  formation 
of  a  true  urethral  canal;  3.  anastomosis  of  the  new  urethra  with  the 
one  already  present. 

[It  is  performed  as  follows :  Make  a  transverse  incision  through  the 
central  portion  of  the  band  uniting  the  glans  to  the  hypospadic  opening, 
cutting  through  the  tissue  layer  by  layer  until  the  fibrous  envelope  of  the 
corpora  cavernosa  is  reached,  incising  it  together  with  the  septum  be- 
tween the  bodies  until  all  incurvation  of  the  penis  is  overcome. 

This  procedure  results  in  the  formation  of  a  lozenge-shaped  area, 
which  should  be  closed  by  a  few  sutures  in  order  to  diminish  the  for- 
mation of  scar-tissue. 

Next  freshen  the  lips  of  the  depression  representing  the  meatus  and 
fasten  a  piece  of  catheter  between  them ;  or,  if  the  depression  is  too  slight 
to  permit  the  formation  of  a  meatus  in  this  manner,  make  a  median  in- 
cision, or  two  small  lateral  incisions,  into  the  substance  of  the  glans 
penis  and  sew  the  catheter  in.  After  healing  has  taken  place  the  new 
urethra  is  formed  in  the  following  manner.     Lift  up  the  penis  and  make 


MALFORMATIONS    OF    THE    URETHRA. 


181 


two  longitudinal  incisions  parallel  to  the  median  line  and  extending 
from  the  base  of  the  glans  to  within  i  or  \  centimeter  (-§— \  of  an 
inch)  of  the  hypospadic  opening;  join  each  extremity  of  these  incisions 
by  a  transverse  cut,  thus  forming  two  quadrilateral  flaps.  Now  pass  a 
catheter  through  the  previously  formed  meatus,  along  the  denuded  under 
surface  of  glans,  and  turn  the  cutaneous  surface  of  the  flaps  over  the 
catheter,  bringing  the  raw  surface  outward.  Next  prolong  the  trans- 
verse incisions  outward,  and  dissect  up  two  new  flaps  sufficiently  large  to 
cover  over  the  raw  surface  of  the  first  ones,  over  which  they  are  turned 
and  sutured  with  fine  silver  wire.     It  is  important  that  the  external  flaps 


Wf    ml    \ 

f 

f 

\ 

1           ■! 

Fig.  152. — Beck's  operation. 
(Binnie,  after  C.  H.  Mayo.) 


Fig.  153. —  Beck's  operation. 
(Binnie,  after  C.  H.  Mayo.) 


be  sufficiently  large  to  encompass  the  catheter  and  internal  flaps  without 
making  immoderate  tension. 

If  this  operation  proves  successful  it  is  a  simple  matter  to  join  the  old 
and  new  urethra.  Freshen  the  edges  of  the  hypospadic  opening,  pass  a 
catheter  from  the  meatus  through  the  canal  into  the  bladder,  and  close 
the  opening  with  metallic  sutures. 

Carl  Beck,  of  New  York,  has  devised  an  ingenious  operation  for  the 
relief  of  balanic  hypospadias,  consisting  in  dissecting  free  the  existing 
urethra  and  drawing  it  to  the  end  of  the  glans  penis  through  a  channel 


182 


DISEASES    OF    THE    URETHRA    AND    PENIS. 


cut  along  the  under  surface  of  the  glans,  or  tunnelled  through  the 
substance  of  the  glans  from  tip  to  base  by  means  of  a  narrow  bistoury 
or  a  small  trocar.  Thus  a  new  canal  is  not  formed,  but  the  urethra 
itself  is  made  to  do  the  service  of  a  new  passage. 

Beck  describes  his  operation  practically  as  follows:  A  transverse  in- 
cision is  made  across  the  lower  surface  of  the  glans,  embracing  the  hypo- 
spadiac  opening.  The  lower  margin  of  the  wound  is  pulled  down  so  as 
to  expose  the  end  of  the  urethra  and  permit  its  separation  from  the  ad- 
joining tissues.     A  longitudinal  incision  is  now  made   alongside   the 


Fig.  154. — Beck's  operation. 
(Binnie,  after  C.  H.  Mayo.) 


Fig.  155. — Beck's  operation. 
(Binnie,  after  C.  H.  Mayo.) 


median  line  of  the  groove.  Two  flaps  are  dissected  up,  one  on  either  side, 
and  the  urethra  freed  still  further  down  until  it  can  be  drawn  to  the  ex- 
tremity of  the  glans  penis  without  tension.  (Fig.  152.)  By  dissecting 
the  edges  of  the  hypospadiac  groove  two  flaps  are  formed,  which  are 
cut  off  in  order  to  give  a  freshened  surface  (Fig.  153);  or  a  narrow 
bistoury  is  plunged  into  the  tip  of  the  glans  penis  and  carried  down 
to  the  site  of  the  hypospadiac  opening  (Fig.  154).  The  urethra  is 
now  pulled  through  the  channel  thus  made,  whichever  it  may  be,  and 
sutured  to  its  distal  end.  The  flaps  of  integument  are  now  brought 
together  over  the  urethra.     (Fig.  155.) 


FISTULA   OF   THE    URETHRA.  1 83 

The  removal  of  a  bit  of  tissue  from  the  external  orifice  affords  a  hard, 
firm  meatus. 

(b)  Epispadias.  Epispadias,  or  cleft  penis,  is  a  malformation  in 
which  the  opening  of  the  urethra  is  on  the  upper  side  of  the  penis.  If 
the  opening  lies  directly  behind  the  glans  the  condition  is  known  as 
epispadias  glandis,  and  if  between  the  glans  and  the  symphysis  as 
epispadias  penis.  In  both  conditions  the  upper  wall  of  the  urethra 
remains  open,  so  that  in  its  place  a  cleft  or  furrow  is  formed.  Behind  the 
groove  where  the  real  urethra  begins  there  is  usually  a  funnel-shaped 
dilatation  called  the  infundibulum.  If  the  entire  urethra  down  to  the 
bladder  is  open,  so  that  the  cleft  extends  directly  into  the  bladder,  we 
then  have  to  do  with  a  complete  epispadias. 

As  in  hypospadias  the  penis  is  more  or  less  stunted  and  is  also  curved 
upward;  other  malformations  or  arrests  of  development  are  seldom 
wanting;  thus,  the  prostate  may  be  absent,  the  testicles  atrophied  or 
undescended;  congenital  hernia,  non-union  of  the  pubic  bones,  non- 
closure of  the  bladder,  and  even  fissure  or  ectopia  vesicae  are  not  unf  re- 
quent  complications. 

The  principal  symptom  of  epispadias  is  dribbling  of  urine,  which 
causes  a  continuous  moisture  and  an  exceedingly  troublesome  eczema. 
This  involuntary  discharge  of  urine  is  due  to  faulty  development  of  the 
vesical  sphincter. 

The  treatment  of  epispadias  is  purely  surgical.  It  consists  either  in 
directly  uniting  the  edges  of  the  urethral  fissure  or  in  performing  a  plastic 
operation. 

The  first  procedure  was  successfully  carried  out  several  times  by  Dieff- 
enbach,  although  at  present  the  plastic  operation  devised  by  Thiersch, 
or  its  modification  according  to  Duplay,  is  employed  because  it  gives 
more  certain  results.  Thiersch's  operation  is  performed  in  the  follow- 
ing stages :  conversion  of  the  furrow  in  the  glans  into  a  duct  having  its 
orifice  on  the  extremity  of  the  glans;  transformation  of  the  cleft  in  the 
body  of  the  penis  into  a  tube;  union  of  the  two,  closure  of  the  infun- 
dibulum. 

FISTULA   OF  THE  URETHRA. 

With  the  exception  of  fistulous  passages  in  hypospadias  congenital 
fistulas  of  the  urethra  are  very  rare.  They  are  formed  during  intra- 
uterine life  to  provide  for  the  exit  of  urine  when  a  portion  of  the  urethra 
is  obliterated. 


184  DISEASES    OF    THE    URETHRA    AND    PEXIS. 

Acquired  fistulae  of  the  urethra  in  man  (the  condition  in  the  female 
does  not  come  under  our  subject)  are  divided,  according  to  the  locality  in 
which  their  orifice  is  found,  into  urethro-rectal,  perineo-scrotal,  and 
penile  fistulae. 

The  urethro-rectal  fistulas  develop  as  a  result  of  trauma  (fracture  of 
the  pelvis,  injury  during  operation),  from  suppuration  in  a  neighboring 
organ  (prostatic  abscess),  and  from  extension  of  a  malignant  new  growth 
or  tubercle  from  surrounding  parts  (carcinoma  of  the  rectum  or  prostate, 
or  tuberculosis  of  these  organs). 

As  a  result  of  the  abnormal  communication  either  a  portion  or  the 
entire  quantity  of  urine  is  voided  through  the  rectum;  conversely, 
although  it  is  of  rare  occurrence,  the  fasces  may  be  expelled  through  the 
urethra. 

The  prognosis  as  to  cure,  except  in  the  case  of  fistulas  due  to  prostatic 
abscess,  is  bad.  Large  sounds  may  be  passed  in  order  to  make  the 
caliber  of  the  urethra  as  free  as  possible,  and  cauterization  of  fistulous 
canals  with  silver  nitrate  or  zinc  chlorid,  or  the  gal vano- cautery,  may 
be  tried;  but  these  procedures  give  hope  of  only  slight  success. 
Plastic  operations  likewise  are  usually  failures. 

The  most  rational  thing  to  do  is  to  make  a  prasrectal  incision,  separate 
the  urethra  from  the  rectum,  freshen  the  edges  of  both  openings  and 
unite  them  by  suture.  If  deemed  necessary  suprapubic  cystotomy  may 
be  performed  so  as  to  supply  another  conduit  for  the  urine  while  the 
wound  is  healing. 

Urethral  fistulas  in  the  perineum  and  scrotum  are  seldom  of  traumatic 
origin.  In  the  vast  majority  of  cases  they  are  due  to  the  urethra  opening 
externally  behind  a  stricture.  Urinary  abscess  or  infiltration  are  re- 
sponsible for  this  occurrence.  More  rarely  it  is  suppuration  of  Cowper's 
or  other  periurethral  glands,  prostatic  abscess,  tuberculous  or  syphilitic 
ulceration  (disintegrating  gummata),  which  are  responsible  for  the 
development  of  fistulas. 

If  the  fistula  pursues  a  straight  course  and  has  a  small  opening,  or  if 
there  is  no  induration  of  the  surrounding  tissues,  it  will  usually  suffice  to 
restore  the  caliber  of  the  urethra  (dilatation  or  internal  urethrotomy); 
in  dealing  with  cicatricial  fistulas  in  which  the  adjacent  parts  are  scarred 
or  indurated  this  procedure  will  not  be  sufficient.  After  the  urethra  has 
been  thoroughly  dilated  the  edges  of  the  fistula  must  be  freshened.  For 
this  purpose  cauterization  with  silver  nitrate  or  tincture  of  iodine,  or  with 
the  galvano-cautery,  should  first  be  tried.     A  surer  way  is  to  split  the 


INJURIES    OF    THE    PENIS.  1 85 

fistulous  canal  and  thoroughly  curette  it.  In  cases  in  which  there  is  a 
considerable  loss  of  substance  excise  the  entire  wall  of  the  fistula,  form- 
ing a  funnel  having  its  apex  in  the  urethra,  separate  the  mucous  mem- 
brane from  its  adjacent  tissues,  and  suture  the  individual  layers  together. 
A  catheter  fastened  into  the  bladder,  or  even  a  suprapubic  cystotomy,  to 
prevent  the  urine  coming  in  contact  with  the  fistula,  will  favor  healing. 
Fistulas  opening  into  the  penile  urethra  are  likewise  formed  behind 
strictures,  and  furthermore  develop  as  the  result  of  gunshot  wounds, 
kicks,  injuries  with  stones,  gangrene  of  the  penis  after  strangulation 
(paraphimosis),  periurethral  abscess,  softening  of  a  gumma,  and  also 
from  phagedenic  chancres.  Cauterization,  suture  of  the  freshened  edge 
when  there  is  no  loss  of  substance,  and,  lastly,  plastic  operations,  gen- 
erally produce  a  cure. 

INJURIES  OF  THE  PENIS. 

Injuries  of  the  penis  are  rare.  They  may  be  divided  into  simple 
contusions,  fractures,  and  luxations.  The  contusions  are  character- 
ized by  copious  extravasations  of  blood,  which  generally  comes  from 
the  corpora  cavernosa.  After  healing  takes  place  protuberant  scars 
called  nodes  remain.  Treatment  consists  in  placing  the  penis  at  rest 
and  applying  clothes  wet  with  a  solution  of  aluminum  acetate.  The 
effusion  is  resorbed. 

In  graver  injuries  due  to  violence  the  urethra  is  generally  involved. 
The  accompanying  conditions  have  been  discussed  under  injuries  of 
the  urethra,  so  we  will  merely  state  here  that  the  laceration  or  partial 
fracture  of  the  corpora  cavernosa  is  frequently  associated  with  retention 
of  urine,  which  makes  it  necessary  to  lay  the  affected  parts  freely  open, 
clear  out  the  blood-clots,  suture  the  laceration  in  the  urethra,  and  fasten 
a  catheter  into  the  bladder  to  prevent  the  urine  gaining  access  to  the 
lacerated  urethra  and  causing  urinary  infiltration. 

In  luxation  of  the  penis  the  organ  is  pushed  into  the  scrotum,  under 
the  skin  of  the  upper  portion  of  the  thigh,  or  upward  over  the  pubic 
bone  {Luxatio  penis  scrotalis,  femoralis,  hypogastrica).  In  these  cases, 
too,  the  urethra  may  be  lacerated.  The  penis  must  be  brought  back  to 
its  normal  position,  the  wound  opened  freely,  haemorrhage  arrested  by 
ligature  or  suture,  according  to  the  nature  of  the  case,  and  the  condition 
of  the  urethra  carefully  attended  to,  a  catheter  being  retained  if  injury  of 
any  extent  has  been  inflicted. 

In  order  to  satisfy  morbid  sexual  impulses  foreign  bodies  [metal  or 


1 86  DISEASES    OF    THE    URETHRA    AND    PENIS. 

celluloid  rings,  for  example]  are  sometimes  drawn  over  the  penis,  and, 
owing  to  interference  with  the  venous  outflow,  remain  firmly  fastened 
behind  the  glans  so  that  they  cannot  be  removed.  It  is  frequently  im- 
possible to  free  the  penis  without  surgical  intervention.  The  strangula- 
tion must  be  incised,  a  grooved  director  passed  under  the  ring,  and  the 
latter  removed  with  forceps,  saw,  or  file. 

BALANITIS,  (BALANOPOSTHITIS,)   GONORRHOEA  OF   THE 

GLANS. 

Suppurative  inflammation  of  the  superficial  mucous  membrane 
covering  the  glans  penis,  the  coronary  sulcus,  and  the  inner  layer  of  the 
foreskin  is  called  balanitis. 

The  most  frequent  cause  of  this  loathsome  disease  is  uncleanliness, 
the  secretion  from  Tyson's  sebaceous  glands,  which  is  very  profuse,  accu- 
mulating and  becoming  decomposed.  In  the  uncleanly  balanitis  is 
often  due  to  the  accumulation  of  gonorrhceal  pus  beneath  the  prepuce. 
In  addition  to  these  causes  the  pus  of  a  soft  or  hard  chancre,  violent 
coition,  condylomata,  herpes,  eczema,  in  short,  any  form  of  irritation, 
may  lead  to  inflammation  of  the  mucosa  of  the  glans.  It  supervenes, 
however,  only  when  proper  cleanliness  of  this  part  of  the  body  is  neglect- 
ed. If  the  glans  were  washed  twice  or  thrice  daily  there  is  scarcely  any 
irritation  which  would  produce  inflammation.  Persons  who  have  no 
prepuce  never  get  balanitis,  their  mucous  membrane  having  been  con- 
verted into  epidermis. 

In  the  beginning  the  patients  experience  an  annoying  sense  of  heat  in 
the  penis ;  as  the  disease  progresses  this  sensation  is  converted  into  one 
of  actual  pain.  Generally  a  glance  at  the  organ  reveals  the  nature  of 
the  trouble.  The  prepuce  in  the  region  of  the  corona  is  distended,  and 
often  so  swollen  that  it  cannot  be  drawn  back  over  the  glans.  If  it  can 
be  retracted  a  profuse,  malodorous,  purulent  discharge  will  issue  forth. 
After  it  subsides  the  surface  of  the  glans  is  seen  to  be  reddened  in 
spots,  prone  to  bleed,  sensitive,  eroded,  and  deprived  of  its  epithelium. 
The  whole  prepuce  may  be  swollen  and  cedematous,  so  that  an  inflam- 
matory phimosis,  or  if  the  foreskin  has  been  previously  retracted,  a 
paraphimosis,  results.  If  either  of  these  conditions  be  not  relieved,  gan- 
grene can  easily  supervene  and  the  necrosed  parts  slough  away. 

After  frequently  recurring  balanitis  the  prepuce  gradually  becomes  so 
thickened  and  rigid  that  it  cannot  be  retracted  over  the  glans.     During 


PHIMOSIS    AND    PARAPHIMOSIS.  1 87 

coition  it  becomes  torn,  and  as  the  lacerations  and  cracks  heal  more  and 
more  contraction  takes  place. 

A  very  unpleasant  complication  of  balanitis  is  the  formation  of  prepu- 
tial calculi.  They  are  composed  of  thickened  smegma  and  deposits  of 
urinary  salts.  Urethral  calculi  may  also  be  deposited  in  the  preputial 
sac  and  remain  there  because  of  the  narrow  orifice.  Preputial  calculi, 
then,  are  usually  the  result  of  balanitis,  but  may  also  be  its  cause  when 
they  originate  from  the  urine.  They  are  capable  of  causing  great  pain 
and  may  interfere  with  coition;  therefore  their  removal  is  indicated. 

For  the  prevention  of  balanitis,  as  already  mentioned,  nothing  but 
personal  cleanliness  is  usually  required.  If,  despite  regular  bathing, 
the  disease  should  begin  to  manifest  itself,  astringent  washes  may  be 
prescribed  in  order  to  diminish  the  secretion  of  the  glands.  Potassium 
permanganate  i :  3000  or  aluminum  acetate  2  per  cent  are  useful. 

In  all  developed  cases,  too,  in  which  the  affection  is  not  complicated 
with  phimosis  it  is  best  to  employ  cleansing,  disinfectant  washes.  The 
foreskin  should  be  drawn  back  and  the  penis  immersed  in  one  of  the 
above  mentioned  solutions,  or  in  corrosive  sublimate  1 :  5000,  or  in  lead- 
water,  after  which  a  pledget  of  cotton  should  be  inserted  between  the 
prepuce  and  glans  in  order  to  keep  the  inflamed  surfaces  apart.  In 
case  the  foreskin  is  rather  too  narrow  to  admit  the  cotton,  the  glans  may 
be  dusted  with  a  drying  powder  such  as  tannin  or  dermatol  [or  com- 
pound stearate  of  zinc].  If  ulcerations  are  present  a  salve  containing 
1-2  per  cent  of  silver  nitrate,  applied  after  thorough  cleansing,  will  be 
found  best  to  heal  them. 

PHIMOSIS  AND  PARAPHIMOSIS. 

The  term  phimosis  is  applied  to  a  condition  of  preputial  narrowing 
in  which  it  is  impossible  to  uncover  the  glans  penis  by  retracting  the 
foreskin.  This  constriction  may  be  either  congenital  or  acquired  and 
is  of  different  degrees.  The  most  pronounced  grades  are  those  in  which 
not  even  the  end  of  the  glans  can  be  uncovered ;  in  cases  of  milder  degree 
retraction  of  the  prepuce  is  possible  if  force  be  employed. 

These  latter  cases,  however,  are  easily  converted  into  complete 
phimosis  by  the  slightest  venereal  infection,  or  even  by  uncleanliness. 
If  a  prepuce  previously  normal  becomes  constricted  by  inflammation 
and  the  glans  also  swells,  a  phimosis  develops  although  there  was  no 
predisposition  present. 

Such  changes  in  the  foreskin  and  glans  penis  may  be  occasioned  by 


1 88  DISEASES    OF    THE    URETHRA    AND    PENIS. 

gonorrhoea,  balanitis  (q.  v.),  chancroid,  chancre,  condylomata,  new 
growths,  and  injuries.  The  exact  cause  of  a  particular  case  will  often 
be  determined  only  after  the  phimosis  has  been  reduced. 

Diagnosis  of  this  affection  is  made  easy  by  the  appearance  of  the 
penis  and  failure  to  retract  the  foreskin. 

Relief  of  the  condition  is  urgently  demanded,  especially  if  the  cause 
is  not  known.  If  neglected  when  sclerosis  or  a  serpiginous  soft  sore, 
for  example,  is  the  cause,  great  deformity  of  the  penis,  and  also  fistulae. 
may  result. 

As  to  treatment,  an  attempt  may  first  be  made  to  secure  relief  by  clean- 
liness and  the  use  of  antiphlogistics.  The  penis  should  be  soaked  in 
antiseptic  solutions  such  as  lead- water,  corrosive  sublimate  i :  5000, 
acetate  of  aluminum  2  per  cent,  and  some  of  the  fluid  injected  between 
the  foreskin  and  the  glans;  the  penis  should  also  be  bound  to  the  abdo- 
men, rest  ordered,  and  clothes  wet  with  aluminum  acetate  solution 
applied.  If  these  measures  fail,  and  if  the  phimosis  is  of  long  duration, 
so  that  there  is  no  prospect  of  their  proving  successful,  recourse  should 
be  had  to  operation. 

The  operation  for  phimosis  is  easy  and  free  from  danger,  and  can  be 
done  under  Schleich's  infiltration  anaesthesia.  A  dorsal  incision  divid- 
ing both  layers  of  the  foreskin  is  made  with  knife  or  scissors,  using  a 
grooved  director  as  a  guide,  and  sutures  introduced  on  both  sides.  If 
the  prepuce  is  very  long  a  triangular  flap  may  be  removed  from  each 
side,  the  apex  of  the  triangle  being  toward  the  corona,  and  enough 
sutures  introduced  to  control  haemorrhage  and  keep  the  edges  of  the 
wound  apart. 

Another  method  is  circumcision,  or  complete  removal  of  the  fore- 
skin. The  foreskin  is  drawn  well  over  the  glans,  forceps  applied,  and 
the  portion  anterior  to  the  blades  of  the  instrument  cut  off  with 
scissors  or  knife.  The  mucous  membrane  is  then  divided  and  trimmed 
around  the  corona,  and  the  two  layers  sutured  together. 

[In  adults  this  operation  can  be  satisfactorily  performed  under  local 
anaesthesia,  both  the  cutaneous  and  mucous  layer  of  the  prepuce 
being  infiltrated  with  a  few  drops  of  a  one  or  two  per  cent  solution 
of  cocain.  Adrenalin  should  not  be  used  in  conjunction  with  cocain, 
for  although  it  renders  the  operation  practically  bloodless,  severe 
reactionary  haemorrhage  may  follow  its  use.  I  have  had  one  such 
case  in  my  own  practice  and  know  of  two  others  in  the  practice  of  a 
colleague. 


PHIMOSIS    AND    PARAPHIMOSIS. 


189 


In  children  a  general  anaesthetic  should  be  used. 

After  the  parts  have  been  thoroughly  washed  with  hot  water  and 
green  soap,  followed  by  weak  bichloride  of  mercury  solution  (1-6000), 
which  in  turn  is  washed  away  with  sterile  water,  the  position  of  the 
corona  glandis  is  outlined  on  the  foreskin  with  tincture  of  iodine  or 
potassium  permanganate  solution,  applied  by  means  of  a  sterile 
applicator. 

The  foreskin  is  now  caught  at  the  preputial  opening  with  a  pair  of 


Fig.  156. — The  prepuce  has  been  drawn  forwards  and  the  circumcision  forceps  applied 
The  skin  incision  is  about  to  be  made. 


haemostatic  forceps,  one  above  and  one  below,  and  while  traction 
is  being  made  upon  them,  either  by  an  assistant  or  by  the  left  hand  of 
the  operator  himself,  the  circumcision  forceps  is  applied  obliquely 
from  above  downward  exactly  along  the  line  of  the  corona,  which  has 
previously  been  marked  out  in  the  manner  above  described.  This 
method  of  application  results  in  more  skin  being  taken  from  the 
superior  aspect  of  the  penis  than  from  the  inferior  (Fig.  156).  When 
the  fenestrated  forceps  shown  in  the  illustration  is  used,  the  line  of  the 
corona  should  correspond  to  the  fenestra. 

The  forceps  being  firmly  held  with  the  left  hand,  the  foreskin  is 


190 


DISEASES    OF    THE    URETHRA    AND    PENIS. 


severed  with  a  quick,  sharp  stroke  of  the  scalpel.  It  is  now  removed, 
together  with  the  circumcision  forceps  and  the  haemostatic  forceps 
which  grasped  the  margins  of  the  preputial  orifice.  The  mucous 
layer  of  the  prepuce,  which  still  covers  the  glans  penis,  is  next  divided 


Fig.  157. — The  skin  has  been  cut  off  and  the  mucous  membrane  is  being  divided. 


by  a  dorsal  slit  made  with  a  pair  of  straight  sharp  scissors.  This 
division  should  be  carried  back  to  within  I  of  an  inch  of  the  corona 
(Fig.  157).  If,  as  frequently  happens  in  congenital  cases,  the  mucosa 
is  adherent  to  the  glans,  it  must  be  separated;  and  if  adhesions  due  to 
ulceration  are  present  they  must  also  be  broken  up.     The  flaps  of 


Fig.  158. — The  flaps  of  mucous  membrane  are  about  to  be  trimmed  off.     The 
longitudinal  incision  should  extend  down  as  far  as  the  dotted  line. 

mucous  membrane  thus  formed  are  trimmed  off  with  scissors,  the 
line  of  the  cut  following  the  corona.     It  is  important  not  to  leave  too. 
much  tissue  at  the  fraenum,  lest  there  result  an  unsightly  and  some- 
times troublesome  induration  in  this  locality  when  healing  and  con- 


PHIMOSIS    AND    PARAPHIMOSIS. 


I9I 


traction  shall  have  taken  place.  (Fig.  158).  If  these  directions  are 
followed  there  will  be  a  narrow  band  of  mucous  membrane  encircling 
the  corona.  The  appearance  of  the  parts  is  shown  in  Fig.  159.  An 
area  of  loose  cellular  tissue  is  seen  between  the  mucous  membrane 
and  the  retracted  cut  margin  of  the  skin.  After  complete  haemo- 
stasis  has  been  secured,  the  cutaneous  and  mucous  layers  are  united 
by  a  series  of  interrupted  sutures  of  No.  00  catgut.  Care  should  be 
taken  not  to  include  in  the  suture  any  of  the  loose  cellular  tissue 
between  the  two  layers  (Fig.  160). 

A  wet  dressing  is  the  best  for  forty-eight  or  seventy-two  hours. 


A 


Fig 


!59 


-Appearance  of  the  parts  anteriorly  and  posteriorly  after  skin 
and  mucous  membrane  have  been  removed. 


Either  weak  lead-water  and  laudanum  or  a  saturated  solution  of 
boric  acid  will  be  found  satisfactory.  I  generally  use  the  former.* 
As  soreness  and  swelling  subside  a  dusting  powder  may  be  substituted. 
Some  surgeons  employ  a  dry  dressing  from  the  beginning.  I  have  tried 
both  methods  and  state  unhesitatingly  that  the  wet  dressing  is  better. 
Bransford  Lewis  recommends  a  dressing  composed  of  cotton  enclosed 
in  gauze  and  saturated  with  compound  tincture  of  benzoin,  which  is 
applied  with  a  medicine  dropper.  This  dressing  becomes  firm  upon 
drying  and  affords  good  protection  to  the  raw  surfaces.     It  is  renewed 

*  Objections  to  the  use  of  lead-water  on  a  small  raw  surface  are  entirely  theoretical. 
It  has  been  used  by  Jefferson  College  men  since  the  days  of  S.  D.  Gross. 


192 


DISEASES    OF    THE    URETHRA    AND    PENIS. 


after  four  or  five  days.  As  a  rule,  the  wound  is  entirely  healed  in  a 
week  or  ten  days. 

Should  haemorrhage  occur  after  the  operation,  the  sutures  must  be 
removed,  the  clot  turned  out,  and  the  bleeding  vessels  tied.  To 
prevent  such  an  accident  all  bleeding  points  of  any  size  should  be  tied 
with  fine  catgut  during  the  operation.  This  precaution  will  save 
trouble.] 

Still  another  complication  is  occasionally  observed  in  congenital 
phimosis,  namely,  too  short  a  fraenum.  In  later  years  this  abnormality 
leads  to  imperfect  erections  of  the  penis.     The  fraenum  pulls  the  glans 


Fig.  160. 


Appearance  of  the  parts  anteriorly  and  posteriorly  after  skin 
and  mucous  membrane  have  been  united. 


downward  and  the  former  is  then  easily  torn  during  coition.  Simple 
division  with  the  knife  or  with  the  Paquelin  cautery  generally  is  sufficient 
to  relieve  this  slight,  though  as  to  its  results,  important,  abnormality. 

Paraphimosis  is  a  condition  in  which  the  prepuce  is  retracted  and 
fixed  behind  the  glans  penis  in  such  a  manner  that  it  cannot  be  drawn 
forward.  It  is  often  caused  by  drawing  a  tight  foreskin  back  for  the 
purpose  of  washing  the  glans.  The  result  is  an  annular  constriction 
around  the  glans  which  causes  circulatory  disturbances,  namely,  oedema 
of  the  glans  itself  and  of  the  preputial  mucosa,  producing  a  collar-like 
swelling  around  the  glans.     If  this  condition  is  allowed  to  continue,  in- 


PHIMOSIS  AND  PARAPHIMOSIS. 


J93 


flammation  and  gangrene  of  the  parts  anterior  to  the  constricting  band 
can  easily  supervene,  but  as  a  rule  gangrene  is  confined  to  the  strangu- 
lating ring  itself,  as  a  result  of  which  it  sloughs  and  thus  relieves  the 
paraphimosis. 

In  every  case  of  paraphimosis  reduction  must  be  attempted  at  once  in 
order  to  prevent  more  serious  injury.  [Several  methods  of  reduction 
have  been  devised.  In  many  cases  oedema  of  the  parts  is  the  chief 
obstacle  to  reduction.  In  such  cases  multiple  punctures  with  a  fine- 
pointed  bistoury  or  large  needle,  followed  by  elevation  of  the  penis 
and  the  use  of  hot  moist  applications  for  a  short  time,  will  so  relieve 
the  swelling  that  the  prepuce  can  readily  be  drawn  forward  over  the 
glans  penis.  ^  In  cases  in  which  this  procedure  proves  unsuccessful  or 
in  those  in  which  it  is  not  deemed  advisable  to  try  it,  reduction  may 


Fig.  161. — Reduction  of  paraphimosis.     (Hirsch.) 


often  be  effected  by  encircling  the  penis  behind  the  constriction  with 
the  thumb  and  one  or  two  fingers  of  the  left  hand,  at  the  same  time 
grasping  the  glans  with  the  thumb  and  fingers  of  the  right  hand, 
and  then  simultaneously  drawing  the  swollen  constricted  prepuce 
forward  and  pressing  the  glans  backward  (Fig.  161).  Before  begin- 
ning this  manipulation  it  is  well  to  dust  the  parts  with  talcum  powder 
or  pulverized  starch.  Local  or  general  anaesthesia  may  be  required. 
Children  usuallv  require  a  general  anaesthetic.  If  this  does  not  suc- 
ceed the  constricting  ring  must  be  divided  in  one  or  more  places  until 
the  glans  slips  back  under  the  skin.  After-treatment  consists  in  con- 
fining the  patient  to  bed,  elevating  the  penis  and  applying  wet 
antiseptic  dressings.  In  cases  complicated  with  chancroids  these 
lesions  must  receive  proper  treatment.] 
13 


194  DISEASES    OF    THE    URETHRA    AND    PENIS. 

CHANCROID   (ULCUS  MOLLE). 

Although  in  the  earliest  times  an  ulcer  of  the  genital  organs  character- 
ized by  purely  local  manifestations  was  recognized,  the  doctrine  that 
the  soft  chancre  and  the  syphilitic  sore  are  identical  was  propagated 
at  the  time  of  the  great  epidemic  of  syphilis  at  the  end  of  the  fifteenth 
century.  Basseran,  a  pupil  of  Ricord,  was  the  founder  of  the  presently 
accepted  and  correct  theory  of  duality,  which  holds  that  the  soft  and 
hard  sores  are  due  to  two  distinct  poisons.  The  existence  of  a  mixed 
chancre,  a  sore  which  represents  both  infections,  is  also  acknowledged. 

The  virus  of  chancroid,  although  probably  due  to  a  microorganism, 
has  as  yet  not  been  discovered.  It  is  possible  that  the  bacillus  of  Ducrey, 
or  the  streptobacillus  of  Unna,  may  be  the  specific  cause,  although  the 
question  does  not  seem  to  have  been  decided  beyond  all  doubt.  Len- 
glet  states  that  he  has  reproduced  the  disease  by  inoculating  with 
cultures  of  this  bacillus,  but  his  assertions  have  not  been  sufficiently 
tested.  Until  these  reports  are  confirmed  it  is  well  to  speak  of  the 
virus  of  chancroid. 

Infection  occurs  almost  always  by  direct  contact  during  sexual  in- 
tercourse; indirect  conveyance  of  the  disease  by  clothing,  linen,  the 
finger,  etc.,  taking  place  with  the  greatest  rarity.  Breaches  of  con- 
tinuity, such  as  small  wounds,  excoriations,  and  ruptured  herpetic 
vesicles  favor  infection. 

A  characteristic  property  of  the  chancroidal  virus  is  its  power  to  pro- 
duce new  and  typical  sores  if  the  purulent  secretion  of  the  ulcer  is  in- 
oculated into  another  part  of  the  body  or  transferred  to  a  healthy  person. 
After  the  chancroid  has  become  healthy  and  is  granulating  this  property 
is  lost  and  no  inoculation  sores  can  be  produced.  The  action  of  the 
virus  is  always  local;  systemic  infection  never  occurs.  According  to 
some  authors  it  differs  from  the  syphilitic  virus  in  that  it  is  communi- 
cable to  animals  (rabbits,  cats,  apes),  while  as  is  well-known  animals  are 
not  susceptible  to  lues.  [Recent  experiments  have  proved  that  certain 
anthropoid  apes  are  susceptible  to  the  syphilitic  virus.]  According 
to  others  the  chancroidal  virus  cannot  be  transmitted  to  animals. 

Symptoms.  The  incubation  period,  or  time  between  the  occur- 
rence of  infection  and  the  outbreak  of  the  sore,  is  very  brief.  Even 
within  twenty-four  hours  an  itching  sensation  may  be  felt  and  a  red- 
dened spot  be  found  upon  examination ;  the  latter  soon  becomes  trans- 
formed into  a  papule  with  reddened  edges,  and  then  rapidly  develops 
into  a  pustule.     As  soon  as  the  pustule  ruptures  an  ulcer  is  formed. 


CHANCROID    (ULCUS    MOLLE).  195 

The  whole  occurrence  takes  about  three  or  four  days.  The  ulcer  is 
usually  of  a  round  or  oval  form,  with  sharply  defined  edges,  so  that  in 
the  beginning  it  looks  as  though  it  had  been  cut  out  with  a  punch.  Its 
base  soon  becomes  covered  with  discolored  necrotic  tissue,  the  surface 
being  slimy  yellow  and  the  undermined  edges  red  and  inflamed.  We 
generally  first  see  the  disease  in  this  stage,  as  the  nodular  and  pustular 
stages  often  pass  unnoticed  by  the  patient. 

The  ulcers  are  confined  to  certain  areas;  namely,  those  parts  which 
are  subjected  to  the  greatest  friction  during  coition,  those  where  tears 
or  breaks  in  continuity  of  tissue  take  place,  and  those  where  the  penis 
is  covered  only  by  mucous  membrane  or  thin  skin.  Therefore  they  are 
frequently  found  on  the  fraenum  and  in  the  depression  on  either  side  of 
it,  in  the  coronary  sulcus,  on  the  free  edge  of  the  prepuce,  and  at  the 
orifice  of  the  urethra.  They  seldom  occur  any  distance  back  in  the 
urethra.  Occasionally  they  are  observed  on  the  shaft  of  the  penis  and 
even  on  the  scrotum  or  thigh. 

The  soft  chancre  is  characterized  by  its  multiplicity.  The  ulcers 
frequently  coalesce  and  cause  wide-spread  destruction  of  tissue,  un- 
dermining the  fraenum  and  completely  perforating  it.  If  the  freenal 
artery  is  eroded  severe  haemorrhage  occurs.  The  virus  being  auto- 
inoculable  new  sores  are  frequently  formed  on  contiguous  parts. 

In  conformity  with  the  nature  of  its  progression,  its  tendency  to  heal 
or  to  spread,  the  chancroid  is  designated  as  atonic,  inflammatory,  phage- 
daenic,  serpiginous,  and  gangrenous. 

The  atonic  chancroid  shows  neither  an  inclination  to  heal  nor  a  ten- 
dency to  spread,  remaining  in  the  same  condition  and  of  the  same  size 
for  weeks  or  months. 

The  inflamed  chancroid  is  surrounded  by  a  reddened,  cedematous  zone ; 
as  a  result  of  the  accompanying  swelling  phimosis  can  easily  develop. 

In  phagedaenic  chancroid  there  is  a  gradual  and  steadily  progressive 
molecular  destruction  of  tissue  which  may  last  for  many  weeks.  The 
ulcer  has  no  inclination  to  heal,  but  instead  shows  a  proclivity  to 
spread  over  the  surface  of  the  tissues;  it  does  not,  however,  invade 
their  depths. 

Serpiginous  chancroids  are  those  in  which  the  sloughing  advances  in 
a  certain  direction,  the  surface  previously  affected  healing  as  the  process 
advances,  repair  thus  following  disintegration. 

A  gangrenous  chancroid  is  one  in  which  the  affected  tissue  rapidly 
undergoes  mortification.     The  base  is  covered  with  a  black  or  grayish- 


I96  DISEASES    OF    THE    URETHRA    AND    PENIS. 

black  eschar.  The  gangrenous  process  extends  deeply  so  that  serious 
mutilation  of  the  penis,  as  well  as  haemorrhages,  may  result.  This 
form  of  gangrene  is  not  to  be  confused  with  that  due  to  circulatory  dis- 
turbance such  as  is  caused  by  phimosis  and  paraphimosis. 

Diagnosis.  The  presence  of  a  sore  on  the  penis  can  of  course  be 
determined  by  inspection ;  it  is  to  be  differentiated  from  other  affections 
occurring  on  the  same  parts,  and  above  all  from  the  primary  lesion  of 
syphilis. 

From  a  practical  point  of  view  the  differentiation  is  not  so  important, 
because  if  the  sore  be  syphilitic  its  recognition  will  in  no  way  alter  the 
inevitable  result,  namely,  the  development  of  constitutional  syphilis. 
So,  too,  the  question  is  generally  not  of  great  significance  as  concerns 
treatment,  for  both  soft  and  hard  sores  are  accustomed  to  heal  under 
the  same  threapeutic  measures.  There  are  cases,  however,  in  which  it 
is  of  value  in  respect  to  treatment  to  make  a  differential  diagnosis,  and 
this  is  especially  desirable  in  reference  to  prognosis  and  the  certainty 
demanded  by  patients  concerning  the  nature  of  their  malady. 

The  following  criteria  enable  us  almost  always  to  determine  whether 
we  are  dealing  with  a  chancroid  or  a  syphilitic  chancre. 

The  incubation  period  of  the  syphilitic  sore  is  much  the  longer,  the 
first  manifestations  not  occurring  before  the  fourteenth  day  after  in- 
fection. [The  average  period  intervening  between  inoculation  and  the 
time  at  which  the  patient's  attention  is  attracted  to  a  lesion  on  his  gen- 
itals may  be  stated  as  twenty-one  days.  In  many  instances  there  is 
no  doubt  that  examination  by  a  careful  observer  would  reveal  the 
presence  of  an  incipient  sore  several  days  earlier.]  It  must  be  remem- 
bered, however,  that  a  chancre  may  begin  as  a  soft  sore  and  afterwards 
assume  its  specific  character  (mixed  chancre). 

The  primary  lesion  of  syphilis  is  harder  than  the  chancroid, 
although  if  the  latter  has  been  cauterized  repeatedly  it  may  become 
indurated;  there  are,  moreover,  soft  sores  which  are  subsequently 
followed  by  syphilis. 

Chancroids  have  a  more  abundant  secretion  than  chancres,  producing 
pus  very  freely;  they  are  multiple,  in  contradistinction  to  the  primary 
lesion  of  syphilis,  which  is  single;  the  glandular  swelling  which  accom- 
panies the  chancroid  is  painful  [has  a  tendency  to  suppurate],  and  is 
generally  unilateral,  while  that  associated  with  syphilis  is  indolent  and 
usually  affects  both  sides. 

Oftentimes  disintegrating  gummata  present  the  appearance  of  fresh 


CHANCROID    (ULCUS    MOLLE).  1 97 

soft  sores.  If  they  fail  to  yield  to  ordinary  treatment,  mercury  or 
potassium  iodide  should  be  tried,  as  under  their  use  gummata  readily 
heal,  but  chancroids  are  not  influenced. 

Tuberculous  and  lupoid  ulcers  should  be  differentiated  from  the 
chancroid  by  the  history  of  the  case.  Disintegrating  carcinomata 
hardly  enter  into  the  question,  although  their  separation  from  syphilitic 
ulcerations  is  not  always  easy;  indeed,  I  have  seen  one  case  in  which 
amputation  of  the  penis  was  advised  on  account  of  a  supposed  carci- 
noma heal  rapidly  under  large  doses  of  potassium  iodide,  and  thus 
manifest  its  syphilitic  nature. 

Lastly  herpes  progenitalis  must  be  mentioned.  It  is  a  harmless 
affection  characterized  by  an  eruption  of  groups  of  vesicles,  which  soon 
burst  and  form  small  superficial  erosions.  They  heal  spontaneously 
in  a  few  days. 

Prognosis.  The  prognosis  of  chancroid  is  almost  without  excep- 
tion favorable.  Only  the  serpiginous,  phagedenic  and  gangrenous 
form  can  cause  extensive  destruction  of  the  penis,  and  thus  alarm 
both  patient  and  surgeon.  Generally,  however,  even  these  severe 
forms  can  be  subdued. 

Treatment.  Abortive  treatment  of  chancroid  can  be  recommended 
only  when  the  patient  comes  under  observation  very  early  in  his 
disease;  then  the  sore  may  be  touched  with  zinc  chloride  or  copper  sul- 
phate, or  a  concentrated  solution  of  these  salts  applied  on  a  pledget  of 
cotton  or  lint.  In  rare  cases  this  method  will  prevent  further  develop- 
ment of  the  ulcer,  but,  on  the  other  hand,  there  is  danger  of  its  causing 
inflammation  and  cedematous  swelling  of  the  neighboring  parts.  For 
this  reason  the  slower  and  more  certain  antiseptic,  disinfectant  treat- 
ment, which  is  free  from  danger,  is  to  be  preferred. 

Bichloride  of  mercury  1:5000  and  copper  sulphate  1:100  are  most 
useful  applications.  The  penis,  with  the  foreskin  well  retracted, 
should  be  soaked  four  times  daily  in  one  of  these  solutions,  and  if  there 
is  sufficient  space  between  foreskin  and  glans,  a  fine  pledget  of  cotton 
wet  in  the  solution  should  be  inserted.  Under  this  medication  the  ulcers 
become  clean  and  rapidly  heal. 

If,  by  reason  of  his  occupation  or  other  circumstances,  the  patient 
cannot  practice  this  regimen,  we  must  be  content  to  let  him  use  the 
bichloride  solution  morning  and  evening,  and  after  drying  the  sores 
dust  them  with  iodoform,  dermatol,  or  europhen.  Of  these  drugs  iodo- 
form still  remains  the  best.     It  is  somewhat  deodorized  by  cumarin. 


198  DISEASES    OF    THE    URETHRA    AND    PENIS. 

If  the  fraenum  is  undermined  it  should  be  cut  through;  if  constric- 
tions of  the  foreskin  are  present  the  best  and  quickest  way  to  overcome 
them  is  by  division.  Often,  however,  cleanliness,  rest,  and  the  use  of 
antiphlogistics  will  suffice.  Indolent  ulcers  should  be  frequently 
painted  with  tincture  of  iodine,  and  serpiginous  sores  cauterized  with 
chloride  of  zinc,  or  scraped  with  a  sharp  curette,  burned  with  the 
thermocautery,  and  dressed  with  alcohol  and  iodoform.  Unna's 
mercurial  and  salicylic  acid  plaster  is  sometimes  of  service. 

NEW  GROWTHS  OF  THE  PENIS. 

Lipoma,  fibroma  and  sarcoma  may  develop  in  the  skin  and  con- 
nective tissue  of  the  penis;  the  first  two  are  exceedingly  rare  and  the 
last  does  not  occur  very  often.  The  sarcomata  grow  from  the  fibrous 
septum  between  the  corpora  cavernosa.  Cysts  in  the  skin  of  the  penis, 
athereroma,  enchondroma,  and  a  form  of  osteoma  proceeding  from 
the  fibrous  layer  of  the  corpora  cavernosa,  have  also  been  observed. 

All  of  these  tumors,  however,  are  of  much  less  frequent  occurrence 
than  condyloma  and  carcinoma. 

When  condylomata  are  isolated  or  arranged  in  small  clusters  they 
do  not  offer  any  difficulties  as  regards  diagnosis  and  treatment.  They 
are  easily  recognized  as  fine  papillary  excrescences,  and  should  be 
removed  and  the  base  treated  with  5  per  cent  resorcin  in  order  to 
prevent  recurrence. 

In  other  cases  the  disease  is  so  neglected  that  large  tumors  develop, 
resembling  malignant  cauliflower  excrescences,  and  covering  the  entire 
glans  or  even  the  shaft  of  the  penis.  They  disintegrate,  decom- 
pose, and  form  ichorous,  stinking  masses,  thus  giving  rise  to  a  condi- 
tion which  often  leads  one  to  doubt  whether  he  is  not  dealing  with  a 
true  carcinoma.  To  differentiate  in  these  doubtful  cases  cut  off  a  few 
of  the  tumors;  whereupon,  if  the  condition  is  benign,  normal,  though 
perhaps  atrophied  skin,  will  be  found  on  the  glans,  the  atrophy  being 
due  to  long-continued  pressure  by  the  tumor.  [If  deemed  desirable  a 
small  mass  may  be  cut  away  and  examined  microscopically.] 

Papillary  excrescences  perforating  the  epidermis  and  extending  into 
the  deep  tissues  are  to  be  considered  as  carcinomata.  Their  most 
frequent  form  is  the  squamous-celled  epithelioma,  which,  owing  to  the 
formation  of  multiple  papillary  excrescences,  together  with  disintegration 
and  generation  of  foul  secretion,  soon  assumes  a  large  and  formidable 
aspect,  and  gradually  invades  the  deep  portions,  extending  to  the  cor- 


PLATE    I 


CARCINOMA    OF    THE    PENIS    (RODMAN.) 


NEW    GROWTHS    OF    THE    PENIS.  ^99 

pora  cavernosa  and  sometimes  even  penetrating  the  urethra.  Of  more 
seldom  occurrence  is  the  soft  form  of  cancer,  the  medullary  carcinoma, 
which  in  its  incipiency  appears  as  circumscribed  nodules;  these  soon 
disintegrate  and  form  sanious  ulcerations,  which  horribly  disfigure  and 
mutilate  the  penis. 

The  prognosis  of  carcinoma  of  the  penis  depends  entirely  upon  the 
stage  in  which  the  patient  comes  under  treatment.  If  no  metastases 
are  present  a  remarkably  large  number  of  patients  can  be  perma- 
nently cured.  Unfortunately  the  cases  are  seldom  seen  early  enough. 
Generally  metastases  are  present,  which  first  affect  the  inguinal  glands, 
later  the  glands  of  the  pelvis  and  those  along  the  iliac  vein. 

The  treatment  of  new  growths  of  the  penis  is  entirely  surgical.  In 
the  case  of  fibromata,  myomata,  cysts,  and  osteomata  the  tumors  should 
be  removed,  as  much  of  the  penis  as  possible  being  spared. 

Condylomata  which  have  attained  large  size  must  be  removed.  By 
proceeding  cautiously  it  will  generally  be  possible  to  preserve  the  penis 
intact. 

In  dealing  with  carcinoma  conservative  procedures  cannot  be  prac- 
tised, amputation  of  the  penis  being  necessary,  and  the  line  of  incision 
being  carried  into  healthy  tissue  whenever  practicable;  indeed,  if  the 
latter  requisite  be  impossible,  operation  might  better  be  left  undone. 
Before  deciding  upon  operation  it  is  well  to  recall  the  fact  that  syphilis 
may,  under  certain  conditions,  cause  large  tumor-like  ulcerations  on  the 
penis,  and  if  doubt  exists  to  give  energetic  doses  of  potassium  iodide. 
[Here  again  microscopic  examination  of  a  small  piece  of  tissue  is  of 
value.] 

Amputation  of  the  penis  is  performed  in  two  ways,  according  as  the 
organ  must  be  removed  in  its  mobile  portion  or  from  the  roots. 

To  amputate  in  the  mobile  portion  draw  the  skin  well  back  and  sever 
the  organ  with  one  or  two  sweeps  of  the  scalpel,  cutting  well  back  in  the 
healthy  tissue  behind  the  tumor.  Catch  the  spurting  vessels,1  especially 
the  dorsal  artery  of  the  penis  above  and  the  artery  of  the  urethra  below, 
with  haemostatic  forceps  and  tie  them,  draw  the  end  of  the  urethra 
somewhat  forward,  notch  it  at  two  opposite  points,  and  join  it  to  the 
skin  of  the  penis  by  a  few  sutures  made  to  include  the  corpora  cavernosa. 
A  short  catheter  should  be  introduced  into  the  urethra  and  fastened 
there  so  as  to  keep  the  wound  from  being  contaminated  with  urine. 
[If  desired,  the  corpus  spongiosum  may  be  separated  from  the  corpora 
cavernosa  and  divided  a  little  anterior  to  the  line  where  the  latter  are 


200  DISEASES    OF    THE    UEETHRA    AND    PENIS. 

cut.  This  procedure  makes  the  urethra  somewhat  longer  and  reduces 
the  liability  of  retraction. 

The  results  obtained  by  the  usual  operative  procedures  are  frequently 
unsatisfactory  as  regards  their  cosmetic  effect,  and,  moreover,  the  patient 
is  often  annoyed  by  dribbling  of  urine  upon  the  scrotum  and  thighs. 

In  order  to  avoid  these  unpleasant  features  Witzel  has  devised  the 
following  ingenious  operation. 

An  extensive  oval  incision  is  made  through  the  skin  on  the  dorsal 
surface  of  the  penis,  a  flap  dissected  up  and  turned  back,  the  dorsal 
vessels  ligated,  and  the  corpora  cavernosa  cut  through  down  to  the 
urethra,  which  is  then  divided  a  centimeter  anterior  to  them.  Each 
corpus  cavernosum  is  now  closed  by  a  row  of  vertical  sutures  passed 
through  their  fibrous  capsule,  the  resulting  line  of  suture  thus  being 
horizontal.  This  manner  of  suturing  draws  the  urethra  somewhat 
upwards,  but  in  order  to  carry  it  still  further  up  over  the  stump  a 
buried  silk  suture  is  passed  through  its  anterior  end.  The  suture  is 
made  to  traverse  the  fibrous  capsule  of  the  corpora  cavernosa,  the 
periurethral  tissue,  and  the  superficial  portion  of  the  wall  of  the 
.urethra,  although  it  does  not  encroach  upon  the  mucous  membrane. 
The  orifice  of  the  urethral  stump  now  lies  at  the  base  of  the  flap.  A 
slit  |  of  a  centimeter  long  is  made  in  the  flap  and  the  urethra  drawn 
through  it.  The  posterior  surface  of  the  urethra  is  now  divided  for  the 
distance  of  h  centimeter,  and  the  new  external  urethral  orifice  formed 
by  suturing  the  edges  to  the  skin.  The  flap  is  then  drawn  down, 
trimmed  if  necessary,  and  sutured  to  the  skin  on  the  under  side  of  the 
penis.     Only  a  few  sutures  are  required. 

The  scar  is  on  the  under  side  of  the  stump,  so  that  the  urine  is  dis- 
charged in  the  normal  manner.  By  properly  trimming  and  adjusting 
the  dorsal  flap  all  unsightly  folds  of  skin  are  done  away  with.] 

If  the  penis  has  to  be  removed  at  its  root,  the  stump  should  not  be  left 
in  the  natural  place  because  excoriations,  eczema,  etc.,  will  be  produced 
by  the  inevitable  wetting  which  results.  Thiersch's  method  of  making 
a  longitudinal  incision  in  the  midline  of  the  perineum,  freeing  the  root 
of  the  penis  from  its  surrounding  tissue,  severing  it,  drawing  the  stump 
into  the  incision  and  suturing  it  there  should  be  adopted.  The  urethral 
opening  will  then  lie  just  in  front  of  the  anus. 

The  operation  for  carcinoma  of  the  penis  cannot  be  considered  com- 
plete unless  all  diseased  inguinal  glands  are  removed.  The  field  of  oper- 
ation is  reached  by  making  a  large  incision  parallel  to  Poupart's  liga- 


ELEPHANTIASIS.  201 

ment,  and  a  second  perpendicular  to  the  first,  following  the  course  of  the 
femoral  vein.  The  skin-flaps  thus  formed  are  dissected  up  and  a  care- 
ful enucleation  of  the  glands  made.  The  glands  are  situated  alongside 
the  vein  and  often  grow  around  it.  In  some  cases  it  is  possible  to  spare 
the  vein,  but  in  others  it  has  to  be  ligated.  This  part  of  the  operation 
is  much  more  difficult  than  the  simple  amputation  of  the  penis  above 
described. 

ELEPHANTIASIS. 

This  disease  is  rare  and  is  observed  after  gonorrhoea,  stricture  or 
injury,  and  also,  as  Konig  has  demonstrated,  in  persons  from  tropical 
countries  in  whom  there  is  no  recognizable  cause  for  its  development. 
The  elephantine  masses  attain  their  characteristic  form  as  the  result  of 
repeated  inflammation  of  the  lymphatic  vessels.  The  tumor,  which 
most  frequently  originates  from  the  prepuce,  soon  invades  the  skin  of 
the  penis,  and  may  assume  enormous  dimensions,  sometimes  reaching 
below  the  knees.  The  penis  itself  may  not  be  damaged,  so  that  much 
of  it  can  be  preserved  when  the  growth  is  removed. 

Before  operating  a  cord  should  be  tied  around  the  root  of  the  penis. 
After  splitting  the  penis  on  its  dorsal  surface  it  can  be  learned  whether 
the  prepuce  alone  or  the  penis  itself  is  affected.  The  amount  of  tissue 
which  can  be  saved  will  be  determined  by  the  superficial  and  deep 
extent  of  the  tumor.  In  desperate  cases  amputation  of  the  penis  is 
necessary. 

CAVERNOUS  INFILTRATION  AND  INDURATION  OF 
THE  PENIS. 

If  urethritis  extends  into  the  urethral  follicles,  inflammation,  or  fol- 
liculitis, results.  The  follicles  can  be  felt  as  small  nodules  about  the 
size  of  millet-seeds.  These  follicular  infiltrations  generally  undergo 
resolution,  but  they  may  proceed  to  suppuration  and  discharge  into  the 
urethra. 

Folliculitis  may,  however,  extend  beyond  the  follicles  and  involve  the 
perifollicular  tissue.  With  the  exception  of  those  in  the  fossa  navi- 
cularis  the  follicles  of  the  urethra  are  imbedded  in  the  tissues  of  the 
corpora  cavernosa.  If  the  inflammation  goes  beyond  the  follicles  and 
perifollicular  tissue  cavernous  infiltration  is  the  result.  These  in- 
filtrates, which  are  now  in  relation  with  both  the  urethra  and  the  penis, 
may  develop  into  nodular  protuberances  which  terminate  in  resolution 


202  DISEASES    OF    THE    URETHRA    AND    PENIS. 

just  as  the  follicles  do,  or  rupture  into  the  urethra,  break  externally, 
or  even  empty  themselves  in  both  directions.  In  addition  to  these  cir- 
cumscribed cavernous  infiltrates,  diffuse  inflammation  of  the  corpora 
cavernosa  also  occurs.  If  the  process  is  acute  it  may  undergo  resolution 
or  proceed  to  suppuration. 

Instead  or  terminating  in  either  of  these  ways  it  may  become  chronic 
and  cause  induration  and  formation  of  fibrous  tissue,  as  a  result  of 
which  permanent  interference  with  erection,  which  may  be  sufficient  to 
cause  impotence,  is  produced.  All  these  conditions — folliculitis,  acute, 
circumscribed,  and  diffuse  cavernitis — may  begin  during  any  stage  of 
urethritis  from  the  acute  to  the  chronic,  and  also  during  the  develop- 
ment of  a  stricture.  The  degree  of  alteration  produced  in  the  urethra 
depends  upon  the  extent  of  the  induration.  The  slowly  developing, 
painless,  chronic  thickening  of  the  corpora  cavernosa  may  become  so 
large  as  to  extend  completely  around  the  entire  circumference  of  both 
bodies  and  thus  cause  flexion  of  the  penis  during  erection.  The  thick- 
ening may  occur  either  as  one  or  more  nodules  or  as  a  lamina.  It  may 
be  limited  to  one  corpus  cavernosum,  but  in  many  instances  it  affects 
both. 

In  making  the  diagnosis  lues  must  be  thought  of,  as  in  this  disease 
gummata  may  be  present  in  the  corpora  cavernosa.  Differentiation 
is  important  in  respect  to  treatment.  The  gummata  yield  readily  to 
antisyphilitic  treatment,  while  induration  of  the  cavernous  bodies  due 
to  chronic  circumscribed  or  diffuse  inflammation  is  not  influenced  by 
it.  Inunctions  of  mercurial  ointment  or  applications  of  mercurial 
plaster,  moist  compresses,  electricity,  and  the  use  of  large  sounds  may 
be  tried  in  an  effort  to  bring  about  resorption,  although  the  result 
obtained  by  these  measures  is  slight. 

LYMPHANGITIS. 

Inflammation  of  the  lymphatics  of  the  penis  usually  follows  gonor- 
rhoea or  chancroid ;  in  rare  instances  it  results  from  some  other  cause, 
being  due  to  injury,  herpes,  or  balanitis.  The  infecting  organisms  gen- 
erally pass  through  the  lymphatics  without  producing  any  disturbance, 
just  as  the  gonococcus  passes  through  the  vas  deferens  without  infecting 
it,  the  inflammation  first  manifesting  itself  in  the  epididymis.  In  excep- 
tional cases,  however,  in  which  the  lymphatic  vessels  are  inflamed,  one 
or  two  sensitive,  cord-like  swellings,  varying  in  size  from  a  thread  to  a 
lead-pencil   and   presenting  nodular   enlargements  unequally  distant 


LYMPHADENITIS.  203 

from  one  another,  can  be  felt  and  seen  along  the  dorsum  of  the  penis. 
The  skin  over  these  cords  is  generally  somewhat  infiltrated  and  red- 
dened. Under  appropriate  treatment  the  process  almost  always  under- 
goes resolution,  the  hard  cords  becoming  gradually  softer  and  smaller 
and  the  entire  infiltrate  becoming  absorbed.  It  is  very  unusual  for 
suppuration  to  ensue.  When  it  occurs  it  is  confined  to  the  little 
intumescences,  which  become  converted  into  small  abscesses  about  the 
size  of  a  bean. 

Treatment  consists  in  rest  and  elevation  of  the  penis.  It  should 
be  bound  to  the  abdomen  and  cloths  wet  with  aluminum  acetate 
applied;  at  night  an  application  of  mercurial  ointment  may  be  made. 
If  an  abscess  breaks  it  is  treated  according  to  general  principles,  being 
cleansed  with  sublimate  solution  and  dusted  with  iodoform. 

LYMPHADENITIS. 

If  pathogenic  microorganisms  invade  the  lymph  glands  as  a  result  of 
injury  (excoriations,  herpes,  scratches),  or  infection  (gonorrhoea,  ulcers), 
they  may  give  rise  to  an  inflammatory  and  infectious  process.  Espe- 
cially in  chancroid  is  this  the  case,  the  glands  becoming  enlarged  and 
painful  and.  showing  a  tendency  to  suppurate.  In  gonorrhoea  this  com- 
plication is  much  rarer,  and  when  it  does  occur  usually  remains  station- 
ary, seldom  progressing  to  pus-formation.  In  syphilis  it  is  still  rarer, 
the  virus  establishing  itself  in  certain  glands  and  producing  only  in- 
significant swelling.  Therefore  it  is  as  a  complication  of  chancroid 
that  we  most  frequently  see  glandular  swellings  of  considerable  size; 
they  are  generally  unilateral,  rarely  bilateral.  In  gonorrhoea  the 
enlargement  is  not  so  pronounced,  affects  both  sides,  and  as  a  rule 
remains  stationary,  while  in  syphilis  it  manifests  itself  as  a  chain 
of  small  isolated  glands,  which  are  like  a  string  of  pearls  imbedded 
beneath  the  skin. 

These  glandular  tumors  are  situated  in  the  groin  for  the  reason  that 
the  lymphatic  vessels  of  the  penis  empty  into  the  inguinal  glands. 

As  long  as  the  inflammatory  process  is  confined  to  the  glands  them- 
selves, the  latter  are  freely  movable  under  the  skin.  They  vary  in 
size,  some  being  as  small  as  a  pea,  others  as  large  as  a  hazel-nut.  If  the 
periglandular  connective  tissue  becomes  involved  the  whole  picture  be- 
comes changed.  The  tumor  is  no  longer  movable,  being  replaced  by 
an  indurated,  painful  swelling  which  makes  it  impossible  to  detect  in- 
dividual glands.     If  the  inflammation  advances  liquefaction  of   the 


204  DISEASES    OF    THE    URETHRA    AND    PENIS. 

tissues  occurs,  the  pain  increases,  and  movement  of  the  thigh  becomes 
difficult;  notwithstanding  this,  however,  fluctuation  is  not  detectable, 
because  the  pus  lies  too  deep  in  the  tissues.  It  works  its  way  to  the  sur- 
face slowly,  causing  the  skin  over  the  tumor  to  become  tense  and  red- 
dened, and  making  it  gradually  thinner  and  thinner,  so  that  if  the 
abscess  is  not  opened  it  breaks  externally  of  its  own  accord.  It  is 
rare  for  only  a  single  gland  to  be  thus  affected;  generally  several  are 
involved,  although  it  may  be  impossible  to  isolate  them,  as  the 
abscesses  which  they  produce  become  confluent. 

If  these  suppurating  buboes  are  not  operated  upon  considerable 
damage  to  the  groin  may  result.  The  entire  skin  down  to  the  thigh 
may  be  undermined.  After  spontaneous  rupture  and  discharge  of 
the  nectrotic  tissue,  fistulous  tracts  often  persist  after  healing  has  taken 
place.  When  due  to  chancroid  the  suppurating  bubo  may  assume  a 
specific  character,  as  it  is  infected  with  the  chancroidal  virus.  The 
lesion  is  then  known  as  inguinal  chancroid.  It  may  become  serpiginous, 
phagedasnic,  or  gangrenous  exactly  the  same  as  simple  chancroid. 

The  diagnosis  of  inguinal  bubo  presents  no  difficulties.  Its  differ- 
entiation from  hernia  might  possibly  arise,  but  the  soft  elastic  character 
of  the  latter  tumor,  its  alteration  in  size  when  the  patient  coughs  and 
likewise  when  he  changes  from  the  upright  to  the  recumbent  posture, 
the  reducibleness  of  the  tumor,  or  if  it  be  irreducible,  the  tympanitic 
note  which  it  emits  upon  percussion,  and  finally,  if  it  be  strangulated, 
the  phenomena  of  intestinal  obstruction  and  the  small  frequent  pulse, 
assure  a  correct  differential  diagnosis. 

The  prognosis  of  inguinal  bubo  is  always  favorable. 

Treatment  is  governed  by  the  nature  of  the  causative  ailment  and  by 
the  stage  in  which  the  disease  comes  under  observation.  Enlarged 
lymphatic  glands  caused  by  syphilis  require  no  other  treatment  than 
rest  and  inunctions  of  mercurial  ointment  or  the  application  of  Unna's 
mercurial  plaster. 

Similar  treatment  is  suitable  for  gonorrhceal  bubo.  Rest,  appli- 
cations of  ice- water  to  which  a  little  acetate  of  lead  or  aluminum  has 
been  added,  together  with  the  nightly  application  of  mercurial  ointment 
or  plaster  as  long  any  danger  of  suppuration  is  feared,  are  appropriate 
therapeutic  measures.  In  the  later  stages,  when  the  glands  remain  chron- 
ically enlarged,  inunctions  of  iodine-vasogen  or  potassium  iodide  oint- 
ment may  be  tried,  or  the  glands  may  be  painted  with  tincture  of  iodine. 

These  antiphlogistic  measures  are  also  indicated  in  bubo  of  chan- 


LYMPHADENITIS.  205 

croidal  origin  provided  the  process  is  not  so  far  advanced  that  suppura- 
tion already  exists  in  the  deep  tissues.  In  the  latter  case,  and  also  if 
tenseness  and  discoloration  of  the  skin  reveal  the  presence  of  pus  in  the 
superficial  tissues,  these  measures  are  ineffective,  and  incision  must  be 
practised.  A  long  deep  cut  is  made  over  the  tumor  parallel  to  Pou- 
part's  ligament,  the  pus  liberated  and  the  abscess  cavity  tamponed  with 
iodoform  gauze.  Pockets  in  the  abscess  must  be  sought  out  and  opened, 
and  necrotic  cutaneous  borders  cut  away;  it  is  also  a  good  practice  to 
scrape  out  the  abscess  with  a  sharp  curette.  If  these  procedures  are 
omitted  fistulae  may  result.  Any  fistulas  present  must  be  split  open  and 
curetted.  In  phagedaenic  and  gangrenous  buboes  the  base  of  the 
wound  should  be  powdered  with  iodoform. 

Excision  of  the  glands  before  the  occurrence  of  suppuration,  or  in  the 
beginning  of  suppuration  before  the  pus  has  broken  through  the  glan- 
dular capsule,  is  being  practised  less  and  less.  The  lymph-glands  act 
as  protectors  to  the  organism  and  removal  should  not  be  countenanced 
unless  it  is  actually  demanded.  If  a  part  of  them  can  be  preserved  ex- 
tirpation is  not  appropriate,  for  it  occasionally  happens  that  glands 
which  have  undergone  partial  suppuration  become  restored  without 
operation,  the  pus  in  them  being  resorbed. 

In  beginning  suppuration  the  abortive  treatment  of  Lang  or  Welander 
may  be  tried.  After  puncture  and  evacuation  of  the  pus  Lang  makes 
repeated  injections  of  a  small  quantity  of  a  ^  per  cent  silver  solution 
into  the  tumor  with  a  Pravaz  syringe  and  applies  a  moist  dressing, 
which  is  later  substituted  by  a  firm  compress.  Welander  uses  a  i  per 
cent  solution  of  benzoate  of  mercury. 

[M.  K.  Taylor  injects  from  10  to  40  minims  of  carbolic  acid  solution 
of  the  strength  of  ten  grains  to  the  ounce. 

Iodoform  injections  in  the  treatment  of  suppurating  bubo  were  first 
recommended  by  Helme.  The  method  was  somewhat  modified  by 
James  R.  Hayden,  of  New  York,  and  has  been  extensively  practised  by 
Orville  Horwitz,  of  Philadelphia. 

The  field  of  operation  is  rendered  surgically  clean  and  cocain  solution 
injected  over  the  bubo.  A  sharp  bistoury  is  then  plunged  into  the  ab- 
scess, the  pus  forced  out  by  firm  pressure,  the  abscess-cavity  irrigated 
first  with  hydrogen  peroxide  and  then  with  bichloride  of  mercury 
1:5000;  when  it  has  been  thoroughly  emptied  a  syringeful  of  10  per 
cent  iodoform  emulsion  is  injected,  a  cool  compress  applied  and  a  firm 
spica  bandage  put  on.     The  patient  is  kept  quiet  for  a  day  or  two.] 


2o6  DISEASES    OF    THE    URINARY    BLADDER. 


DISEASES  OF  THE  URINARY  BLADDER. 
ANATOMY  AND  PHYSIOLOGY. 

The  urinary  bladder  lies  in  the  true  pelvis  behind  the  symphysis  pubis, 
being  bounded  posteriorly  and  laterally  by  the  peritoneum  and  the 
obliterated  umbilical  arteries,  superiorly  by  the  urachus,  and  inferiorly 
by  the  prostate  and  pelvic  fascia.  Its  size,  form  and  position  vary 
with  its  degree  of  fulness.  In  the  form  of  a  triangle  when  empty,  it 
assumes  an  ovoid  shape  when  full,  its  shortest  diameter  extending  from 
before  backwards  and  its  longest  running  from  above  downwards. 
Its  capacity  in  adults  varies  from  300  to  600  cc.  [10  to  20  fluid  ounces]. 

The  anterior  surface  of  the  bladder  is  entirely  free  from 
peritoneum,  being  connected  to  the  abdominal  wall  by  a  thick  layer 
of  loose  connective  tissue.  Further  down  it  is  fastened  to  the  symphysis 
by  bands  of  firmer  connective  tissue  called  pubo-vesical  ligaments. 
The  space  in  front  of  the  bladder  filled  with  loose  connective  tissue  is 
known  as  the  prevesical  space  or  the  space  of  Retzius.  The  posterior 
surface  is  entirely  covered  with  peritoneum,  which  separates  it  from  the 
rectum  in  the  male  and  from  the  uterus  and  broad  ligaments  in  the 
female.  The  superior  surface  is  likewise  covered  with  peritoneum. 
The  inferior  surface  is  in  relation  with  the  rectum,  the  prostate,  the 
seminal  vesicles,  and  the  vasa  deferentia. 

In  the  interior  of  the  bladder,  on  its  inferior  surface,  the  trigonum  of 
Lieutaud  is  seen,  which  is  bounded  by  the  ureteral  orifices  and  the  in- 
ternal orifice  of  the  urethra.  The  muscular  fasciculi  covered  with  mu- 
cous membrane  which  are  seen  projecting  from  the  inner  surface  of  the 
bladder  are  continuations  of  the  ureteral  musculature  and  are  known  as 
the  ligamentum  inter -uretericum. 

That  portion  of  the  bladder  in  which  the  urethra  commences  is  called 
the  neck.  It  is  encircled  by  the  internal  sphincter  muscle,  which  is 
formed  by  the  circular  muscular  fibers  of  the  bladder. 

The  bladder-wall  is  composed  of  a  serous,  muscular,  and  mucous 
coat.  The  nature  of  the  serosa,  which  is  identical  with  the  peritoneum 
covering  the  bladder,  has  already  been  described. 

The  muscularis  is  composed  of  longitudinal  and  transverse  fibers 
which  cross  one  another,  and  when  more  fully  developed  form  a  trabe- 


ANATOMY    AND    PHYSIOLOGY.  207 

cular  reticulum  which  has  given  the  name  of  trabecular  bladder  or 
vessie  a  colonnes  to  those  bladders  in  which  it  is  present. 

The  mucosa  is  pale,  being  somewhat  more  vascular  near  the  neck 
than  elsewhere.  It  has  no  villi  and  when  the  bladder  is  full  no  plica- 
tions. The  existence  of  glands  has  been  denied  by  Sappey,  but  others 
have  demonstrated  the  presence  of  small  rudimentary  mucous  follicles, 
especially  in  the  region  of  the  neck.  The  epithelium  of  the  mucosa  is 
cuboid  and  cylindric  in  the  deep  layers,  then  of  the  pavement  variety, 
while  the  most  superficial  portion  consists  of  large  squamous  cells. 

The  arteries  of  the  bladder  are  derived  from  the  hypogastric,  some 
coming  direct  and  others  being  given  off  by  branches  of  the  internal 
iliac.  [The  superior  vesical  artery  is  really  the  unobliterated  portion  of 
the  hypogastric  artery ;  the  middle  vesical  is  either  derived  directly  from 
the  hypogastric  or  is  given  off  from  the  superior  vesical;  the  inferior 
vesical  is  a  branch  of  the  internal  iliac.  In  the  female  the  uterine  and 
vaginal  arteries  also  send  a  few  twigs  to  the  bladder.]  They  anastomose 
on  the  outer  surface  of  the  bladder,  penetrate  its  wall,  and  form  a  vascu- 
lar net- work  beneath  the  mucosa. 

The  numerous  veins  form  a  triple  net- work,  one  set,  which  is  especially 
large,  being  under  the  mucosa,  the  second  intermuscular,  and  the  third 
subperitoneal.  All  these  vessels  unite  with  the  dorsal  veins  of  the  penis 
and  the  plexus  of  Santorini  and  eventually  empty  into  the  iliac.  This 
venous  system  is  slightly  developed  in  youth,  becomes  well-developed 
in  middle  life,  and  in  old  age  sometimes  grows  so  large  as  to  form  well- 
marked  glomeruli. 

The  lymphatic  vessels,  the  existence  of  which  has  been  denied,  empty 
into  the  lymphatic  glands  of  the  pelvis. 

The  nerves  are  derived  from  the  hypogastric  plexus  and  from  the 
anterior  branches  of  the  third  and  fourth  sacral  nerves. 

The  sensibility  of  the  body  of  the  bladder  to  touch  is  not  great. 

The  vesical  neck  is  much  more  sensitive.  When  it  is  touched  with  a 
foreign  body,  such  as  a  sound  for  example,  considerable  pain,  or  at  least 
a  desire  to  urinate,  is  generally  experienced.  In  diseased,  inflamed 
bladders  this  sensibility  is  increased. 

The  sensibility  of  the  bladder  to  distention  is  considerable.  When- 
ever a  certain  quantity  of  urine,  which  in  healthy  persons  varies  from 
300  to  500  cc.  [10  to  15  fluid  ounces]  accumulates,  a  desire  to  urinate  is 
felt,  which  becomes  greater  and  greater  and  increases  to  a  distinct  feel- 
ing of  pain  if.  the  bladder  is  not  emptied.     In  disease  this  sensibility  is 


208  DISEASES    OF    THE    URINARY    BLADDER. 

much  greater.  There  are  inflammations  of  the  mucous  membrane  or 
of  the  entire  bladder-wall  in  which  even  a  minimum  quantity  of  urine 
gives  rise  to  acute  pain. 

In  response  to  this  irritability  of  distention  the  bladder  contracts. 
The  thicker  its  walls,  the  greater  its  power  of  resistance.  Under  nor- 
mal conditions  it  seldom  ruptures,  but  if  deep  ulcerations  or  diverticula 
are  present  tears  of  the  bladder  may  easily  result  from  pressure,  espe- 
cially pressure  exerted  from  without. 

Micturition  is  an  act  under  the  control  of  the  will.  The  theory  that 
the  vesical  contractions  producing  it  are  caused  by  impingement  of  a  few 
drops  of  urine  upon  the  prostatic  urethra  is  erroneous,  as  they  result 
from  distention  of  the  entire  vesical  wall. 

So,  too,  the  prevalent  idea  that  the  vesical  mucous  membrane  does  not 
absorb  is  erroneous  and  not  to  be  accepted.  It  is  true  that  absorption 
takes  place  slowly  and  with  difficulty  in  a  healthy  bladder,  but  yet  it  does 
take  place  to  a  certain  extent.  An  inflamed,  hypersemic,  or  even  an 
ulcerated  bladder  absorbs  more  readily  than  one  which  is  not  diseased . 
These  facts  must  be  considered  in  cocainizing  the  bladder. 

CYSTITIS. 

At  present  we  understand  by  the  term  cystitis  an  inflammation  of  the 
bladder  due  exclusively  to  infection.  The  bacteria  in  the  bladder 
cause  suppuration.  Therefore  in  every  case  of  cystitis  pus  and  micro- 
organisms are  found  in  the  urine.  Whenever  pus  is  present  in  the 
bladder  bacteria  are  also  present;  bacteria,  however,  may  be  present 
without  producing  suppuration.  In  such  cases  we  have  a  condition 
known  as  bacteriuria. 

Certain  bacteria  occasion  cystitis,  although  certain  conditions  must 
be  present  to  prepare  a  favorable  soil  for  their  reception  and  growth. 
Such  predisposing  causes  are  trauma,  congestion,  retention  of 
urine,  or  a  combination  of  these  conditions.  Experiments  have  shown 
that  under  certain  conditions  pathogenic  microorganisms  can  be  intro- 
duced into  the  bladder  without  giving  rise  to  a  cystitis  ;  if  injury  be  in- 
flicted, however,  or  congestion  produced,  as  for  example,  by  occluding 
the  urethra,  then  a  cystitis  develops. 

When  cystitis  occurs  after  catheterization  or  the  passage  of  a  stone, 
its  evolution  is  to  be  explained  by  the  fact  that  some  injury,  however 
slight  it  may  have  been,  was  inflicted  at  the  same  time  the  microorgan- 
isms gained  entrance  to  the  bladder. 


CYSTITIS.  209 

The  cystitis  which  supervenes  after  ingestion  of  cantharides,  or  after 
exposure  to  cold,  may  be  accounted  for  by  supposing  that  the  congestion, 
which,  as  is  well-known,  follows  the  use  of  this  drug,  and  which  may  also 
be  caused  by  cold,  prepares  a  suitable  ground  for  microorganisms  al- 
ready present.  Repeated  violent  copulation,  masturbation,  constipa- 
tion or  hemorrhoids  may  also  lead  to  congestion  of  the  bladder. 

Old  people,  especially  prostatics,  are  more  subject  to  cystitis,  because 
they  do  not  completely  empty  their  bladder,  so  that  a  partial  retention 
of  urine  results  which  makes  it  possible  for  microbes  to  take  up  their 
abode  and  propagate. 

Which  bacteria  are  to  blame?  A  large  number  have  been  found 
or  named,  some  by  one  investigator  and  some  by  another.  We  will 
not  mention  them  all,  but  will  name  only  those  which  have  been  most 
frequently  observed.  The  following  microorganisms,  named  in  the 
order  of  frequency  with  which  they  are  present,  are  to  be  considered  as 
the  cause  of  cystitis:  bacterium  coli  communis,  streptococcus,  proteus 
Hauser,  bacillus  tuberculosis,  displococcus  urece  liquefaciens,  staphy- 
lococcus ureas  liquefaciens,  streptobacillus  anthracoides,  gonococcus, 
and  bacillus  typhosus. 

The  formerly  prevalent  theory  that  the  presence  of  a  ferment  which 
converts  urea  into  ammonium  carbonate  was  necessary  for  the  develop- 
ment of  cystitis  has  now  been  abandoned.  Rovsing  maintained  that 
only  such  bacteria  as  generated  this  ferment  could  cause  cystitis.  We 
know,  however,  that  most  cases  of  the  disease  are  associated  with  acid 
urine,  a  condition  which  precludes  the  possibility  of  decomposition  taking 
place.  In  other  cases  it  may  and  does  happen,  but  its  occurrence  is 
secondary;  as  a  primary  cause  of  cystitis  it  does  not  exist. 

The  question  as  to  how  the  bacteria  reach  the  bladder  now  presents 
itself  to  our  consideration,  and  in  answer  thereto  it  may  be  stated  that 
they  gain  access  by  four  routes,  namely,  through  the  urethra,  the  kidneys, 
the  blood,  and  the  wall  of  the  bladder  itself. 

First,  as  concerns  the  urethra,  it  is  to  be  borne  in  mind  that  a  whole 
series  of  microorganisms  inhabit  the  healthy  urethra  of  both  sexes,  where 
they  are  not  pathogenic,  or  at  least  remain  latent,  although  they  may 
become  virulent  if  they  get  into  the  bladder,  and  thus  supply  the  re- 
quisites for  the  development  of  disease.  In  this  manner  many  cases  of 
cystitis  in  persons  who  have  never  been  catheterized  are  explained. 
If  urethritis,  gonorrhoea,  or  in  the  female,  leucorrhcea,  is  present,  the 
extension  of  the  infectious  process  is  readily  understood. 
14 


2IO  DISEASES    OF    THE    URINARY    BLADDER. 

That  the  kidneys  sometimes  discharge  microorganisms  into  the  blad- 
der and  thereby  cause  cystitis  is  clearly  demonstrated  in  tuberculosis. 
With  the  cystoscope  it  can  be  seen  that  the  primary  lesion  of  tuberculous 
cystitis  begins  around  the  orifice  of  a  ureter  communicating  with  a  tuber- 
culous kidney.  Like  conditions  due  to  other  organisms  can  be  demon- 
strated experimentally.  Thus  the  colon  bacillus  may  be  excreted  by 
the  kidneys  and  pass  into  the  bladder.  According  as  the  bladder  is  or 
is  not  in  a  condition  of  receptivity,  a  cystitis  develops  or  the  bacilli  are 
carried  out  by  the  urine  without  doing  any  damage.  It  may  also  be 
assumed  that  microorganisms  are  in  like  manner  brought  to  the  bladder 
through  the  blood-stream  or  lymph-channels  and  give  rise  to  cystitis 
if  favorable  conditions  for  their  development  are  present. 

Finally  in  regard  to  a  path  of  infection  through  the  wall  of  the  bladder, 
it  may  be  said  that  such  an  occurrence,  though  not  yet  certain,  is  never- 
theless most  probable.  Wreden,  Posner,  and  Reymond  have  endeavor- 
ed to  prove  it  experimentally,  but  their  conclusions  have  not  remained 
undisputed.  I  am  of  the  opinion  that  bacteria  inhabiting  the  in- 
testines, such  as  the  colon  bacillus,  may,  under  favorable  conditions, 
— as  for  example,  a  slight  lesion  of  the  intestinal  wall,  or  congestion — 
penetrate  the  intestine  and  the  wall  of  the  bladder,  reach  the  interior  of 
the  viscus  and  give  rise  to  a  cystitis  provided  the  conditions  necessary 
for  its  development  are  present. 

Proceeding  from  the  point  of  view  that  every  cystitis  is  infectious, 
and  furthermore  that  a  condition  favoring  the  occurrence  of  infection, 
be  it  congestion,  trauma,  or  retention  of  urine,  must  be  present,  we  can 
make  the  following  classification: 

i .  Cystitis  due  to  extension  of  infection  from  neighboring  parts.  To 
this  class  belong  gonorrhceal  cystitis  and  that  form  of  cystitis  so  com- 
mon in  puerperal  women. 

2.  Cystitis  formerly  known  as  cryptogenetic  or  idiopathic,  and 
which  we  must  assume  to  be  due  to  the  passage  of  infectious  germs  to 
the  bladder  through  the  intestines,  the  blood,  or  the  kidneys.  Under 
this  form  are  included  cystitis  due  to  cold  and  to  irritating  drugs. 

3.  Traumatic  cystitis  (caused  by  calculi  or  foreign  bodies). 

4.  Cystitis  with  retention  (caused  by  stricture,  hypertrophy  of  the 
prostate,  paralysis  of  the  bladder  of  central  origin,  tabes,  myelitis,  etc., 
arteriosclerotic  degeneration  of  the  vesical  musculature). 

5.  Neoplastic  cystitis. 

6.  Tuberculous  cystitis. 


CYSTITIS.  211 

7.  Symptomatic  cystitis,  a  form  in  which  the  vesical  condition  is 
merely  a  symptom  of  some  constitutional  disease,  such  as  pyaemia, 
typhoid  fever,  etc. 

From  a  practical  point  of  view  we  also  distinguish  between  acute  and 
chronic  cystitis,  cystitis  localized  at  the  neck  of  the  bladder  in  contra- 
distinction to  that  affecting  the  body  of  the  viscus,  and  the  circumscribed 
and  diffuse  forms  of  the  disease.  We  no  longer  speak  of  catarrhal, 
purulent,  and  hasmorrhagic  cystitis  because  the  products  of  inflamma- 
tion, now  mucus,  now  pus,  now  blood,  or  indeed  a  mixture  of  the 
three,  represent  nothing  essential  to  the  disease. 

PATHOLOGICAL  ANATOMY. 

In  acute  cystitis  there  is  a  more  marked  vascularization  and  disten- 
tion of  vessels  than  in  health.  This  is  seen  especially  near  the  neck  of 
the  bladder,  the  trigonum,  and  the  base.  The  mucous  membrane  is 
cedematous,  hyperaemic,  and  in  certain  areas  spots  of  ecchymosis  are 
present.  The  epithelium  is  swollen,  and  is  soon  cast  off  and  passed 
with  the  urine.  In  more  severe  grades  of  inflammation  the  disease 
extends  into  the  deep  tissue  and  small-celled  infiltration  of  the  mucosa 
and  muscularis  results. 

In  chronic  cystitis  the  principal  changes  likewise  affect  the  trigonum 
and  neck  of  the  bladder.  The  mucous  membrane  is  gray  in  color,  and 
is  swollen,  thickened,  and  secretes  freely;  its  various  strata,  which  in 
health  are  closely  adherent,  are  now  almost  separated  from  one  another. 
It  is  deprived  of  superficial  epithelium,  while  in  the  deeper  strata  of  epith- 
elia  and  in  thesubmucosa  a  small-celled  infiltration  is  present.  In  some 
cases  typical  granulations  are  seen  on  the  mucous  membrane,  and  when 
extensive  form  a  number  of  small  round  excressences ;  in  other  cases  the 
mucous'  membrane  presents  villous  elongations  and  protuberances, 
which  may  be  mistaken  in  the  cystoscopic  picture  for  papillomata 
(cystitis  vegetans).  (Fig.  162.)  The  process  generally  invades  the 
deep  tissues  and  infiltrates  the  muscularis  with  small-cells;  it  is  un- 
usual for  it  to  extend  beyond  the  muscular  coat  and  lead  to  a  peri- 
cystitis. In  very  severe  grades  of  cystitis  true  ulcerations  occur,  cir- 
cumscribed areas  of  the  epithelium  and  submucosa  becoming  gan- 
grenous and  sloughing  away. 

SYMPTOMS    AND   DIAGNOSIS. 

The  symptoms  of  acute  and  chronic  cystitis  differ  from  one  another 
only  in  intensity,  one  form  frequently  merging  into  the  other.     In  gen- 


212 


DISEASES    OF    THE    URINARY    BLADDER. 


eral  the  disease  is  characterized  by  three  cardinal  symptoms :  Stran- 
gury, pain,  and  pus  in  the  urine.  The  more  acute  the  inflammation 
the  more  pronounced  are  the  first  two  symptoms,  while  the  more  chronic 
it  becomes  the  less  marked  they  are,  so  that  in  many  cases  of  chronic 
cystitis  they  fail  entirely.  Pus,  however,  is  invariably  present  in  the 
urine.  There  is  no  cystitis  without  pus.  This  declaration  still 
holds  good,  although  cystoscopy  has  taught  us  that  we  must  make  a  little 


Fig.  162. — -Cystitis  vegetans  with  papillary  excrescences. 


concession,  for  it  has  shown  that  slight  grades  of  inflammation  character- 
ized by  hyperemia  of  the  mucous  membrane  may  exist  without  there 
being  any  pus  in  the  urine.  These  processes  are  to  be  considered 
rather  as  the  precursors  of  cystitis  than  as  cystitis  itself. 

Let  us  consider  the  special  symptoms  more  accurately.  The 
strangury  is  characterized  by  the  patients  urinating  very  frequently 
without  the  quantity  of  urine  being  increased.  Often  the  voiding  of 
a  few  teaspoonfuls  of  urine  quells  the  desire  to  urinate.     It  is  very 


CYSTITIS.  213 

characteristic  of  cystitis  that  the  urgency  of  urination  persists  day  and 
night,  although  it  is  not  so  severe  at  night  as  during  the  day.  In 
this  respect  it  differs  from  the  urgency  of  nervous  origin,  which  causes 
a  desire  to  urinate  only  at  intervals  during  the  day  and  not  at  all  at 
night.  The  strangury  is  due  to  the  inability  of  the  swollen  mucous 
membrane  to  expand  in  response  to  accumulation  of  urine.  For  this 
reason  it  is  most  severe  in  acute  cystitis. 

So,  too,  pain  is  chiefly  a  symptom  of  the  acute  form.  It  arises  before, 
during,  or  at  the  end  of  micturition.  In  very  acute  cases  it  is  most 
intense  before  the  act,  subsiding  as  soon  as  the  distention  of  the  bladder 
is  relieved.  In  other  cases,  especially  those  in  which  the  inflammation 
is  localized  at  the  neck  of  the  bladder,  the  pain  is  most  severe  at  the  end 
of  urination.  The  location  of  the  pain  varies,  it  being  felt  above  the 
symphysis,  in  the  perineum,  and  especially  in  the  end  of  the  penis.  It 
may  supervene  irrespective  of  micturition  upon  violent  physical  ex- 
ertion, riding  over  rough  roads,  etc. 

The  third  and  most  constant  symptom  of  cystitis  is  purulent  urine. 
The  quantity  of  pus  varies  exceedingly.  The  more  diffuse  the  in- 
flammatory process,  the.more  copious  the  amount  of  pus.  If  the  patient 
urinates  in  several  glasses  the  urine  in  the  last  glass  will  be  the  most 
turbid,  because  it  contains  the  pus  which  sinks  to  the  bottom  of  the 
bladder  and  is  voided  last.  In  this  respect  it  differs  from  the  urine  of 
posterior  urethritis  and  urethrocystitis  {quod  vide). 

Blood  may  or  may  not  be  present  in  the  urine.  It  is  not  a  constant 
symptom;  in  general  it  may  be  stated  that  its  presence  is  exceptional. 
Reference  will  be  made  to  it  again  when  considering  the  particular  forms 
of  cystitis. 

It  has  already  been  stated  that  in  the  majority  of  cases  the  urine  is 
acid.  The  idea  that  the  urine  is  always  ammoniacal  has  been  entirely 
abandoned.  There  are  cases —  usually  those  which  have  been  neglect- 
ed— in  which  the  urea  has  been  decomposed  and  ammonium  carbonate 
formed,  and  in  which  triple  phosphates  (ammonio -magnesium  phos- 
phate) are  always  found  upon  microscopic  examination,  but  this  con- 
dition does  not  belong  essentially  to  cystitis.  Oftentimes  the  micro- 
scope reveals  nothing  but  pus. 

In  the  beginning  of  the  disease,  especially  in  children,  it  is  not  un- 
usual for  a  slight  rise  of  temperature  to  occur,  but  as  the  disease  ad- 
vances the  temperature  becomes  normal  again.  In  subacute  and 
chronic  cystitis  the  temperature  is  almost  always  normal,  and  any  eleva- 


214  DISEASES    OF    THE    URINARY    BLADDER. 

tions  which  take  place  are  to  be  attributed  to  exacerbations  or  com- 
plications. 

As  some  of  the  previously  mentioned  forms  of  cystitis  present  pecu- 
liarities of  symptomatology,  and  also  vary  as  to  their  prognosis,  they 
should  be  accorded  further  consideration. 

Gonorrhoeal  cystitis  is  decidedly  benign.  It  may  supervene  during 
any  stage  of  acute  or  chronic  gonorrhoea;  indeed,  even  when  nothing 
but  a  simple  urethral  catarrh  is  present,  that  is,  one  in  which  gonococci 
no  longer  exist,  a  cystitis  may  suddenly  develop.  It  is  to  be  considered 
as  an  extension  of  the  urethral  inflammation  due  to  bacteria  present  in 
the  urethra  after  the  subsidence  of  the  specific  infection. 

The  symptoms  of  acute  gonorrhoeal  cystitis  are  entirely  different  than 
those  of  the  chronic  form. 

The  acute  form  appears  as  a  cystitis  colli  or  cystocollitis :  severe 
strangury,  excruciating  pain,  especially  at  the  end  of  micturition ,  pus 
in  the  urine,  and  usually  blood  also,  constitute  the  typical  picture  of 
the  disease.  The  strangury  is  of  the  most  severe  type;  it  manifests  it- 
self every  five  or  ten  minutes,  and  because  of  the  pain  associated  with 
micturition  it  becomes  unendurable.  It  robs  .the  patient  of  rest  and 
sleep  and  soon  undermines  his  general  health.  If  the  urine  be  collected 
in  several  glasses  the  first  portion  will  be  found  the  most  turbid,  because 
it  contains  the  pus  from  the  bladder  in  addition  to  that  from  the  urethra. 
At  the  conclusion  of  micturition  a  few  drops  of  pure  blood  or  bloody 
urine  are  voided;  the  latter,  however,  may  be  absent.  This  so-called 
terminal  haemorrhage  is  characteristic  of  inflammatory  disease  at  the 
neck  of  the  bladder. 

As  the  inflammatory  process  becomes  chronic  urgency  of  urination 
and  pain  abate,  or  finally  subside  altogether,  leaving  nothing  but  the 
purulent  urine,  which  when  collected  in  separate  portions  is  found  grad- 
ually to  assume  the  character  of  the  urine  of  cystitis  corporis  as  the  in- 
flammation extends  more  and  more  from  the  neck  to  the  body  of  the 
bladder.  Occasionally  the  clinical  picture  is  different.  All  signs  of 
haemorrhage  may  be  absent,  or  severe  bleeding,  such  as  characterizes 
vesical  tumors,  may  occur.  This  fact  must  be  remembered  in  order  to 
guard  against  error.  This  form  of  gonorrhoeal  cystitis  with  profuse 
haemorrhage  may  lead  the  physician  to  think  that  he  is  dealing  with  a 
very  grave  malady ;  especially  is  this  the  case  when  a  history  of  gonor- 
rhoea is  not  obtainable.  It  must  not  be  forgotten  that  careless  persons 
are  often  unaware  of  the  existence  of  a  slight  chronic  urethritis,  which 


CYSTITIS.  215 

when  it  undergoes  an  exacerbation  may  extend  to  the  neck  of  the  bladder 
and  cause  the  above  mentioned  form  of  cystitis.  Furthermore  the 
favorable  effects  of  treatment  upon  gonorrhceal  or  post-gonorrhceal 
cystitis  serve  to  prevent  confusion;  it  is  plain  that  strangury  and  haem- 
orrhage from  other  causes,  as  for  instance  from  tumors,  are  not  so  easily 
subdued. 

Cystitis  feminas.  The  ordinary  forms  of  cystitis,  such  as  those  due 
to  gonorrhceal  infection,  calculi,  foreign  bodies,  etc.,  naturally  occur  in 
woman  as  well  as  in  man.  Here,  however,  it  is  our  purpose  to  consider 
that  form  which  occurs  especially  in  women  without  the  presence  of  a 
distinct  assignable  cause.  This  idiopathic  cystitis  is  much  more  com- 
mon in  females  than  in  males,  and  is  probably  due  to  the  shortness  of 
the  female  urethra,  as  a  result  of  which  pathogenic  microorganisms 
more  readily  gain  access  to  the  bladder.  This  form  is  especially  com- 
mon during  pregnancy  and  the  puerperium,  periods  in  which  the  dis- 
turbed circulatory  relations  offer  exceptionally  favorable  conditions 
for  the  development  of  cystitis. 

Its  symptoms  and  course  do  not  differ  much  from  those  of  the  other 
forms.  It  is  benign  in  nature  and  yields  readily  to  appropriate  treat- 
ment. Generally  urgency  of  urination,  pain,  and  pus  in  the  urine  form 
the  symptom-complex;  blood  is  seldom  voided. 

Cystitis  arising  from  exposure  to  cold  or  ingestion  of  cantharides 
likewise  pursues  a  benign  course.  It  presents  no  peculiarity  of 
symptoms. 

Traumatic  cystitis,  by  which  is  meant  those  forms  due  to  injury 
produced  by  calculi  or  foreign  bodies,  is  also  of  favorable  prognosis. 
Special  stress  is  to  be  laid  upon  the  circumstance  that  in  this  form  oftener 
than  in  others  exacerbations  associated  with  great  pain  follow  ex- 
ercise and  exertion.  Especially  in  many  cases  of  cystitis  due  to  stone, 
the  so-called  vesical  spasms,  a  condition  in  which  the  patient  is  seized 
with  attacks  of  violent  convulsive  pain  in  the  hypogastrium,  manifest 
themselves.  These  spasms  of  the  bladder  are  difficult  to  control  by 
internal  treatment.  On  the  other  aand,  if  the  source  of  the  evil  can  be 
removed — the  stone  or  foreign  body  got  out  of  the  bladder — they 
usually  subside  very  quickly. 

Cystitis  accompanied  by  retention  of  urine  generally  pursues  a 
chronic  course;  the  fact  must  never  be  lost  sight  of,  however,  that 
every  chronic  cystitis  may  suddenly  become  acute.  Any  baleful  in- 
fluence, such  as  exposure  to  cold  or  excess  in  drinking,  may  cause  a 


2l6  DISEASES    OF    THE    URINARY    BLADDER. 

chronic  and  absolutely  painless  cystitis  to  assume  an  acute  form.  It 
may  then  be  exactly  like  a  first  attack,  being  accompanied  by  severe 
pain,  spasm  of  the  bladder,  etc. 

The  prognosis  of  cystitis  associated  with  retention  of  urine  depends 
upon  whether  it  is  possible  to  relieve  the  retention.  We  have  come 
to  recognize  that  retention  is  one  of  the  conditions  which  favor  the 
development  of  vesical  infection.  It  is  self-evident  then  that  it  will  be 
especially  prone  to  cause  the  persistence  of  an  already  existing  cystitis. 
Thus  it  is  found  that  those  cases  in  which  retention  can  be  overcome 
have  a  decidedly  favorable  course,  while  those  in  which  retention 
persists  are  obstinate. 

Cystitis  due  to  stricture  of  the  urethra  almost  always  gets  well 
after  the  stricture  has  been  sufficiently  dilated.  Prostatics  are  relieved 
of  their  vesical  catarrh — as  we  are  wont  to  call  the  chronic  cystitis  from 
which  they  suffer — by  simple  treatment  as  soon  as  the  congestion  and 
engorgement  of  the  prostate,  and  with  it  the  retention  of  urine,  are  sub- 
dued. The  same  thing  is  true  of  the  forms  dependent  upon  disease  of 
the  central  nervous  system  in  which  the  residual  urine  can  be  reduced 
or  done  away  with.  This  is  not  uncommonly  the  case  in  tabes,  in 
chronic  myelitis,  and,  according  to  my  own  experience,  most  frequently 
of  all  in  spastic  spinal  paralysis.  When  the  retention  persists,  as  for 
example  in  advanced  cases  of  paresis,  or  when  the  residual  urine  of 
prostatics  cannot  be  diminished,  then  the  cystitis  may  equal  it  in  per- 
sistency. It  can  be  ameliorated,  but  seldom  cured.  The  course  of  this 
form  presents  some  peculiarities.  Its  excessive  chronicity  has  already 
been  mentioned.  Furthermore  it  is  worthy  of  notice  that  in  these  cases 
there  is  usually  a  considerable  degree  of  suppuration,  and  that  decom- 
position of  the  urine  takes  place,  the  urea  being  changed  into  ammo- 
nium carbonate.  The  urine  has  an  alkaline  reaction  and  free  alkali  in 
the  form  of  triple  phosphate  is  found. 

If  we  remember  that  in  these  forms  the  bladder  is  generally  trabec- 
ular, its  walls  being  filled  with  recesses  and  pockets  and  its  mucous 
membrane  being  invaginated  between  projecting  columns,  so  that  the 
surface  is  greatly  increased,  it  will  be  readily  understood  that  large 
quantities  of  pus  can  collect;  moreover,  it  will  be  apparent  that  such 
cases  are  very  hard  to  cure,  for  the  reason  that  the  bacteria-laden  urine 
remains  in  the  diverticula,  from  which  it  is  not  easily  removed  by  even 
the  most  thorough  irrigations. 

It  is  also  important  for  a  complete  understanding  of  these  forms  to 


CYSTITIS.  217 

remember  that  in  the  vast  majority  of  cases  the  bladder  has  undergone 
enormous  dilatation.  This  is  a  result  of  constant  pressure  exerted  by 
the  retained  urine  upon  the  bladder  wall.  The  degree  of  distention 
may  be  exceedingly  great.  I  have  seen  patients  whose  bladder  could 
hold  two  liters  [about  two  quarts]  of  urine  without  causing  them  mate- 
rial uneasiness.  As  the  result  of  pressure  pouches  are  formed  which  are 
often  larger  than  the  bladder  itself. 

On  the  other  hand,  instead  of  being  dilated  and  distended  the  cavity  of 
the  bladder  may  be  compressed.  When  the  morbid  process  extends  to 
the  musculature  and  the  latter  becomes  markedly  hypertrophied  the 
cavity  of  the  bladder  may  become  so  small  that  it  cannot  hold  more 
than  30  to  50  cc.  [1  to  i§  fluid  ounces].  Fortunately  this  so-called 
concentric  hypertrophy  of  the  bladder  wall  is  exceptional  in  the  forms 
of  cystitis  already  described.  We  shall  refer  to  these  cicatricial  and 
contracted  bladders  again  in  our  article  on  vesical  tuberculosis. 

The  cystitis  due  to  tumors  of  the  bladder  varies  greatly  in  its  mani- 
festations, according  as  it  depends  upon  a  benign  or  malignant  growth. 
In  the  first  place  we  know  that  neoplasms  may  be  present  in  the  bladder 
without  producing  cystitis.  If  they  give  rise  to  haemorrhage,  however, 
cystitis  usually  develops.  The  growth  of  a  tumor  in  the  wall  of  the 
bladder  causes  circulatory  disturbances  which  favor  the  development  of 
infection. 

While  the  cystitis  which  arises  as  a  result  of  benign  polypi  is  of  a  de- 
cidedly mild  character,  that  which  accompanies  malignant  growths 
is  difficult  or  impossible  to  control.  In  the  former  class  only  slight 
pain  and  scarcely  any  urgency  of  micturition  are  experienced;  the  fre- 
quent haemorrhages  are  due  to  the  tumor  and  not  to  the  cystitis.  When 
the  tumors  are  removed  the  bladder  quickly  heals.  Even  though  the 
tumor  remains  the  symptoms  of  cystitis  soon  disappear  under  appro- 
priate irrigations,  but  relapses  are  prone  to  take  place. 

The  malignant  growths,  carcinoma  and  sarcoma,  tend  to  disinte- 
grate. The  products  of  disintegration  are  retained  in  the  bladder  and 
supply  an  unfailing  source  of  infection.  Even  though  the  symptoms 
improve  exacerbations  due  to  the  same  cause  are  not  long  deferred. 

We  will  not  enter  upon  a  discussion  of  tuberculosis  in  this 
place,  because  we  shall  consider  it  under  tuberculosis  of  the  bladder 
(quod  vide).  We  merely  state  here  that  it  is  the  most  pernicious  of  all 
forms,  that  it  is  characterized  by  unconquerable  pain,  tenesmus,  haem- 
orrhage, and   an  almost  invariable  contraction  of  the  bladder  which 


2l8  DISEASES    OF    THE    URINARY    BLADDER. 

greatly  diminishes  its  capacity.  It  is  upon  this  form  that  all  our  thera- 
peutic efforts  are  often  wrecked — efforts,  too,  which  in  nearly  all  other 
forms  of  cystitis  are  crowned  with  more  or  less  success. 

The  French  school  has  made  a  still  more  minute  classification  of 
cystitis,  having  described  what  they  term  painful  and  membranous 
forms  (cy  stile  doulourense,  cystite  membraneuse).  The  first  is  character- 
ized by  excessive  pain  which  cannot  be  controlled  by  the  ordinary  thera- 
peutic measures.  I  deem  it  unwise  to  separate  this  form  from  the 
others  for  the  reason  that  any  cystitis  may  suddenly  become  very  pain- 
ful. Many  of  these  cases  are  probably  tuberculous,  but  the  diagnosis 
is  not  made  because  the  presence  of  bacilli  cannot  be  demonstrated. 
Some  believe  that  in  many  such  cases  there  has  been  a  pericystitis,  and 
that  the  adhesions  on  the  exterior  of  the  bladder  are  responsible  for 
the  pain. 

Membranous  cystitis  is  peculiar  in  that  large  shreds  or  masses  of 
mucous  membrane  are  discharged.  The  same  thing  is  known  to  take 
place  in  inflammation  of  other  organs,  large  pieces  of  ephithelium  being 
cast  off.     This  form  of  cystitis  presents  no  other  peculiarities. 

In  conclusion  it  should  be  mentioned  that  cystitis  also  occurs  in  very 
young  children.  I  have  seen  gonorrhceal  cystitis  in  a  boy  of  two. 
Cystitis  is  more  common  in  girls,  in  whom  it  is  evident  that  infection 
occurs  through  the  vulva. 

The  diagnosis  of  cystitis  is  exceptionally  easy,  there  being  scarcely 
any  disease  which  can  be  more  readily  and  surely  recognized.  If  stran- 
gury and  painful  micturition  exist,  and  pus  derived  from  the  bladder  is 
present  in  the  urine,  the  diagnosis  is  assured.  A  careful  anamnesis, 
together  with  a  more  complete  examination,  either  with  the  sound  or 
the  cystoscope,  o'r  by  means  of  digital  palpation,  will  then  enable  us  to 
determine  with  which  form  of  the  disease  we  have  to  do. 

The  only  question  which  can  cause  difficulty  is  whether  the  pus  comes 
from  the  bladder.  May  it  not  come  from  the  urethra,  the  prostate, 
the  pelvis  of  the  kidney?  For  the  solution  of  this  problem  the  urine 
should  always  be  collected  in  glasses,  as  other  vessels  do  not  permit  the 
detection  of  slight  turbidity.  Always  have  the  patient  urinate  in  two 
glasses.  The  first  portion  in  the  second  glass  will  represent  the  urine 
from  the  bladder,  the  last  portion  that  from  the  bladder  and  kidneys. 
If  pus  is  present  only  in  the  first  glass  it  is  surely  from  the  urethra  or 
its  neighboring  glands,  such  as  the  prostate. 

But  if  the  urine  in  the  second  glass  is  cloudy,  then  the  source  of  pus 


CYSTITIS.  219 

can  be  only  from  the  bladder  or  kidneys,  or  perhaps  from  both.  The 
differential  diagnosis  between  cystitis  and  pyelitis  may  be  exceedingly 
difficult.  We  shall  refer  to  this  matter  again  in  our  article  on  pyelitis. 
Here  we  shall  merely  emphasize  the  fact  that  painful  micturition,  stran- 
gury, and  alkaline  urine  containing  but  little  albumen  point  to  cystitis. 
It  must  not  be  forgotten,  however,  that  in  most  cases  of  cystitis  the  urine 
is  acid,  so  that  the  teaching  which  formerly  prevailed  to  the  effect  that 
the  reaction  of  the  urine — it  being  acid  in  pyelitis  and  alkaline  in  cystitis — 
furnished  an  infallible  means  of  differentation  can  no  longer  be  accepted. 
Very  little  can  be  determined  from  miscroscopic  examination  of  the 
urinary  sediment,  for  in  pyelitis  nothing  but  pus-cells  may  be  present,  as 
is  the  case  in  cystitis;  in  cystitis,  too,  all  forms  of  epithelium  may  be  ob- 
served, and  those  derived  from  the  deep  layers  of  the  urethra  and  blad- 
der were  formerly  supposed  to  be  the  characteristic  type  of  cells  from 
the  renal  pelvis. 

I  consider  that  great  help  is  derived  from  the  effect  produced  by  treat- 
ment. Every  form  of  cystitis,  with  the  exception  of  those  caused  by 
tuberculosis  and  malignant  growths,  is  benefited  by  irrigation  of  the 
bladder,  but  this  treatment  has  no  effect  upon  suppurative  disease  of  the 
renal  pelvis.  Finally  cystoscopy  and  catheterization  of  the  ureters  offer 
the  most  important  and  trustworthy  means  of  diagnosticating  between 
the  two  affections.     Both  will  be  discussed  under  pyelitis. 

TREATMENT. 

The  treatment  of  cystitis  is  a  very  gratifying  task,  because  the  disease 
is  one  which  is  always  susceptible  of  amelioration  and  one  which  can 
often  be  entirely  cured.  I  premise  that  all  treatment  must  first  of  all 
be  directed  to  removal  of  the  underlying  cause.  Strictures  must  be 
dilated,  stones  or  foreign  bodies  removed.  If  a  suppurating  kidney  is 
the  source  of  the  disease,  cure  will  never  be  obtained  until  the  renal 
disease  is  mastered.  If  a  large  amount  of  residual  urine  is  present,  or 
if  paralysis  of  the  bladder  exists,  regular  catheterization  is  the  prerequi- 
site to  a  possible  cure. 

Here,  too,  as  in  general  medicine,  prevention  must  not  be  underrated. 
As  we  know  that  infection  is  the  cause  of  cystitis  we  must  be  on  the  alert 
to  prevent  its  occurrence.  Careful  washing  of  the  genital  organs, 
especially  in  woman,  but  also  in  man,  and  the  most  scrupulous  asepsis 
in  catheterization  should  be  practised. 


2  20  DISEASES    OP    THE    URINARY    BLADDER. 

There  are  four  principal  therapeutic  measures  at  our  disposal  in  the 
treatment  of  cystitis;  namely,  hygienic,  internal,  local,  and  operative. 

In  the  treatment  of  acute  cystitis  only  the  first  three  are  employed. 
The  hygienic  measures  resorted  to  in  acute  cystitis  comprise  baths, 
applications,  diet,  and  rest.  It  has  long  been  known  that  warmth  exerts 
an  exceptionally  favorable  effect  upon  the  bladder.  We  use  it,  there- 
fore, in  all  conceivable  forms;  warm  full  baths,  hot  sitz-baths,  hot  cata- 
plasms, or  better  still  the  thermophore  applied  over  the  bladder,  usually 
relieve  pain  and  strangury.  In  addition  a  restricted  diet  should  be 
prescribed;  all  highly  seasoned  food,  mustard,  cheese,  radishes,  pungent 
sauces,  etc.,  and  all  alcoholic  beverages,  should  be  interdicted.  It  is 
better  for  the  patient  to  keep  his  bed  in  the  beginning  of  an  acute  cystitis. 
As  the  symptoms  abate  and  the  temperature  becomes  normal  he  may  be 
allowed  to  sit  up,  but  should  still  remain  in  his  room. 

Of  remedies  administered  internally  the  narcotics  hold  first  rank. 
They  lessen  the  sensibility  of  the  bladder,  thereby  diminishing  the  num- 
ber of  painful  contractions,  and  thus,  by  tranquillizing  the  bladder, 
exert  an  indirect  curative  effect.  Morphine,  opium,  or  belladonna 
should  be  ordered  in  pills,  powders,  or  suppositories.  The  dose  is  de- 
termined according  to  the  general  rules  of  practice.  When  given  in  the 
form  of  suppositories  a  somewhat  larger  quantity  should  be  used  than 
otherwise,  because  all  the  drug  is  not  absorbed.  As  an  internal  initial 
dose  0.015  [i  gramJ  of  morphine  or  0.005  [iV  grain]  of  heroin  may  be 
given,  and  the  amount  increased  as  necessary.  The  following  combi- 
nation injected  into  the  rectum  by  means  of  a  small  glycerine-syringe 
is  very  efficacious  in  relieving  pain:  antipyrin  1.0  [15  grains]  or  pyrami- 
don  0.25  [3!  grains],  water  5.0  [i|  fluid  drachms]  laudanum  10  to  20 
drops. 

Urinary  antiseptics  and  diluents  should  be  ordered  at  the  same  time. 
We  shall  refer  to  them  again  under  the  treatment  of  chronic  cystitis. 

As  to  local  treatment,  that  is,  irrigation  of  the  bladder,  it  may  be  stated 
that  it  is  generally  contraindicated  in  acute  cystitis.  The  remedies 
just  mentioned  usually  suffice  to  relieve  the  acute  symptoms  to  such  an 
extent  that  the  strangury  and  pain  become  insignificant,  the  only  essen- 
tial characteristic  of  the  disease  which  remains  being  pyuria.  When 
this  condition  obtains  local  treatment  is  appropriate. 

An  exception  to  the  rule  is  constituted  by  gonorrhceal  cystitis.  This 
form  may  be  so  severe  and  obstinate  that  all  the  hygienic  measures  and 
internal  treatment  above  mentioned  fail  to  relieve  the  pain.     Even  large 


CYSTITIS.  221 

doses  of  morphine  are  of  no  avail.  Such  cases  should  be  treated  during 
the  acute  stage  by  irrigating  the  neck  of  the  bladder  with  a  solution  of 
nitrate  of  silver  after  the  method  of  Diday,  which  was  described  in  the 
article  on  cystitis  colli  gonorrhceica  (quod  vide).  This  treatment  is  more 
effective  than  all  other  measures  combined.  A  few  irrigations  suffice 
to  relieve  the  pain  and  considerably  reduce  the  suppuration. 

In  all  other  forms  of  cystitis  excepting  the  tuberculous,  local  measures 
are  to  be  employed  during  the  stage  of  severe  pain  and  strangury  only 
after  hygienic  measures  and  internal  treatment  have  failed. 

In  the  treatment  of  chronic  cystitis  the  same  hygienic  rules  advised 
for  acute  cystitis  should  be  followed.  Restricted  diet  and  hot  baths  are 
especially  indicated  for  the  exacerbations  which  so  often  occur  as  the 
result  of  exposure  to  cold  or  excess  in  eating. 

Of  the  remedies  administered  internally  the  narcotics,  as  in  acute 
cystitis,  cannot  be  dispensed  with,  because  throughout  its  protracted 
course  exacerbations  are  constantly  occurring.  Whenever  pain  and 
strangury  are  absent  there  is,  of  course,  no  indication  for  their  admin- 
istration. 

Drugs  which  have  the  reputation  of  disinfecting  the  bladder  and 
lessening  suppuration  therein  have  long  played  an  important  role  in 
the  treatment  of  cystitis.  None  of  them  fully  accomplish  this  purpose, 
but  there  is,  however,  a  difference  in  their  value. 

The  balsamics — oil  of  sandal-wood,  balsam  of  copaiba,  oil  of  tur- 
pentine— are  to  be  avoided  as  a  rule,  because  they  are  badly  borne  by 
the  digestive  tract.  I  consider  their  administration  advisable  only  in 
gonorrhceal  cystitis,  in  which  they  are  in  some  measure  beneficial.  If  it 
be  desired  to  try  them  in  the  other  forms  they  should  be  given  only  in 
moderate  doses,  say  40  drops  a  day,  and  only  for  a  short  time. 

A  very  old  and  highly  esteemed  class  of  drugs  used  in  the  treatment  of 
cystitis  is  composed  of  certain  vegetable  substances,  such  as  buchu 
leaves,  couch-grass,  pareira  brava,  corn-silk,  uva  ursa,  alchemilla  and 
others.  The  best  of  these  is  buchu,  which  certainly  exerts  a  soothing 
influence. 

These  herbs  may  be  taken  in  the  form  of  tea,  several  being  mixed 
together  and  two  teaspoonfuls  allowed  to  each  cup  of  water.  The 
patient  should  drink  three  or  four  cupfuls  a  day.  Although  some  of 
the  good  effect  produced  may  be  due  to  the  fact  that  the  urine  is  diluted 
by  the  free  ingestion  of  fluid,  these  medicinal  teas  seem  to  exert  a  spe- 
cific sedative  and  astringent  action  which  is  not  produced  by  simple 


22  2  DISEASES    OF    THE    URINARY    BLADDER. 

diluents.  Care  should  be  taken  to  have  the  tea  actually  boil  for  a  few 
minutes  and  not  merely  simmer,  as  by  the  former  process  the  active 
principles  of  the  herbs  are  withdrawn. 

In  the  treatment  of  cystitis  diluent  drinks  hold  a  rank  of  considerable 
importance.  It  is  evident  that  if  the  urine  is  well  diluted  accumula- 
tions of  pus  v\ill  be  broken  up  and  more  easily  expelled.  We  may  pre- 
scribe diuretics  either  alone  or  in  combination  with  the  decoctions 
above  mentioned,  or  administer  diuretin  in  doses  of  0.5  [7^  grains]  three 
or  four  times  a  day ;  if  preferred  certain  of  the  mineral  waters  may  be 
given.  The  waters  of  the  George  Victor  and  Helena  springs  at  Wild- 
ungen,  Wernarz  spring  at  Briickenau,  Obersalz,  Salvator,  Fachinger, 
Offenbach,  and  Ems  are  alkaline,  and  when  drunk  in  large  quantities 
render  acid  urine  alkaline,  and  make  alkaline  urine  more  strongly 
alkaline.  They  have  a  decidedly  favorable  influence  on  chronic  catarrh. 
The  greater  part  of  their  action  is  due  to  their  diluent  effect,  but  some 
may  be  due  to  the  specific  properties  of  the  waters  themselves.  As 
these  spring-waters  are  expensive,  Dr.  Sandow's  artificially  prepared 
salts,  which  are  of  the  same  composition  as  those  of  the  natural  waters, 
may  be  ordered  for  patients  in  moderate  circumstances. 

A  large  number  of  drugs,  among  which  may  be  mentioned  salicylic, 
benzoic,  camphoric,  carbolic,  and  boric  acid,  potassium  chlorate  and 
nitrate,  the  balsamics,  arbutin  (the  active  principle  of  uvaursa),  salol, 
urotropin  and  helmitol,  have  been  recommended  as  effective  urinary 
antiseptics.  All  were  reputed  to  possess  the  property  of  destroying 
bacteria  in  the  urine,  of  making  it  aseptic,  and  thereby  removing  the 
cause  upon  which  the  continuance  of  cystitis  depended.  The  first  thing 
to  be  remembered  about  them  is  that  none  of  them  fulfilled  that  which 
was  expected  and  desired  of  them.  Some  of  them,  however,  have  a 
decided  influence  upon  the  bacteria  in  the  urine,  and  thus  exert  some 
action  upon  the  catarrh.  Even  though  they  cannot  kill  the  bacteria, 
they  inhibit  their  development  and  prevent  increase  of  their  number. 

According  to  my  experience  this  very  desirable  property  is  possessed 
solely  by  urotropin,  which  is  the  best  urinary  antiseptic  at  our  disposal. 
It  may  be  given  in  powder,  tablets,  or  solution  in  the  dose  of  1-3.0 
[15  to  45  grains]  a  day.  Chemically  it  is  hexamethylene-tetramin,  under 
which  name  it  is  now  on  the  market.  It  works,  as  I  have  proved,  by 
liberating  formalin  in  the  urine.  It  is  well  borne  and  only  rarely  pro- 
duces unpleasant  after-effects.  Burning  in  the  urethra  or  bladder,  and 
occasionally  the  appearance  of  blood,  have  been  caused  by  its  use,  but 


CYSTITIS.  223 

their  occurrence  is  most  exceptional;  generally  the  patients  experience 
no  untoward  effects  from  the  drug,  being  able  to  tolerate  it  for  months 
at  a  time.  When  these  ill-effects  manifest  themselves,  the  drug  should, 
of  course,  be  discontinued  for  a  shorter  or  longer  time,  as  the  exigencies 
of  the  case  demand. 

The  next  drug  to  be  alluded  to  is  salol,  which  is  given  in  doses  of 
2-4.0  [h  to  1  drachm]  a  day,  and  which  is  eliminated  in  the  urine  as 
carbolic  and  salicylic  acid.  It  is  not  borne  very  well  by  the  stomach. 
It  should  be  discontinued  at  once  if  the  urine  shows  the  presence  of 
carbolic  acid. 

Chlorate  of  potassium  acts  well  now  and  then,  but  it  should  not  be 
used  because  of  its  poisonous  properties.  One  patient  can  take  large 
doses,  another  not  even  the  smallest.  Unfortunately  we  cannot  tell 
which  patients  will  tolerate  it  and  which  will  not. 

I  have  seldom  seen  any  good  follow  the  use  of  any  of  the  other  drugs 
mentioned.  Salicylic  and  camphoric  acid,  the  first  in  the  dose  of  2.0 
[30  grains],  the  second  in  the  dose  of  4.0  [60  grains]  daily  may  occasion- 
ally be  used  with  advantage.  Sufficient  evidence  concerning  the  value 
of  the  recently  recommended  helmitol  has  not  yet  been  gathered. 

In  isolated  cases,  especially  those  in  which  the  infection  is  not  severe 
and  the  formation  of  pus  in  the  bladder  is  slight,  the  previously  mentioned 
hygienic  measures  and  internal  medication  are  all  that  is  necessary. 
If  the  character  of  the  urine  does  not  soon  change,  if  its  turbidity  does  not 
materially  diminish,  then  no  time  should  be  lost  in  resorting  to  local 
treatment,  which,  when  properly  conducted,  gives  most  admirable  re- 
sults. I  refer  almost  exclusively  to  irrigation  of  the  bladder  with 
large  quantities  of  fluid.  The  instillation  of  a  few  drops  of  fluid  is 
hardly  ever  practised. 

Irrigation  of  the  bladder  has  a  twofold  object:  it  is  intended  simul- 
taneously to  cleanse  the  bladder  of  bacteria  and  accretions  of  pus 
adherent  to  its  walls,  and  to  stimulate  the  superficial  layer  of  the  vesical 
wall  to  exfoliation,  so  that  a  healthy  surface  from  which  regeneration 
of  the  tissue  shall  take  place  may  remain.  As  for  internal  medication, 
so  likewise  for  this  purpose  a  number  of  substances  have  been  recom- 
mended, among  which  are  permanganate  of  potassium,  permanganate 
of  zinc,  sulphate  of  copper,  carbolic  and  salicylic  acid,  potassium  chlo- 
rate, ichthyol,  lysol,  oxycyanate  of  mercury,  bichloride  of  mercury, 
and  nitrate  of  silver. 

The  last  two  drugs  are  the  most  effective.     Bichloride  is  used  only 


224  DISEASES    OF    THE    URINARY    BLADDER. 

in  exceptional  cases.  The  remedy  par  excellence  is  silver  nitrate. 
It  is  used  in  solution  in  the  strength  of  1 15000-1 :50c  The  best  solu- 
tion for  general  use  is  1 :  1000.  After  the  bladder  has  been  emptied  by 
means  of  a  catheter  it  is  filled  with  the  silver  solution,  as  much  being 
allowed  to  flow  in  through  an  irrigator  or  injected  with  a  syringe  as 
the  bladder  will  tolerate.  Undue  distention  of  the  organ  should  be 
avoided.  For  very  sensitive  bladders  it  is  better  to  use  a  hand  syringe, 
but  for  large  dilated  ones  the  irrigator  is  to  be  preferred.  It  is  impor- 
tant that  the  bladder  be  completely  filled.  The  custom  of  using  small 
quantities  of  fluid,  from  50  to  100  cc.  [ij  to  3  fluid  ounces]  is  in  the 
majority  of  cases  incorrect;  as  the  silver  nitrate  must  come  in  con- 
tact with  all  parts  of  the  bladder  in  order  to  disinfect  it,  the  solu- 
tion must  therefore  be  forced  between  all  duplicatures  and  into  all 
recesses  and  diverticula. 

These  silver  irrigations  are  somewhat  painful  and  also  produce  more 
or  less  strangury.  Therefore  is  is  not  wise  to  employ  them  daily.  I 
seldom  use  them  oftener  than  every  second  day.  It  is  well  to  change 
the  solutions,  using  the  silver  on  one  occasion  and  a  milder  irrigation  on 
the  next.  Of  the  latter  oxycyanate  of  mercury  and  boric  acid  are  the 
best,  the  first  being  used  in  1 :  5000  solution,  the  second  in  a  3  per  cent 
solution.  Their  general  effect  is  to  cleanse  the  bladder;  curative  action 
has  not  been  observed.  All  the  other  drugs  mentioned,  excepting 
bichloride,  may  be  stricken  from  the  list,  as  they  do  not  equal  the 
silver. 

The  bichloride  is  an  unusually  active  remedy  in  vesical  catarrh,  being 
exceedingly  valuable  for  securing  thorough  disinfection.  It  is  not  en- 
tirely free  from  danger  and,  moreover,  is  so  painful  that  it  should  be  used 
as  an  irrigation  only  in  exceptional  cases.  It  is  employed  in  the  strength 
of  from  1 :  10000  to  1 :300c 

It  has  rendered  me  excellent  service  in  the  treatment  of  bacteriuria, 
that  condition  in  which  bacteria  alone,  without  cellular  elements  or 
pus,  are  found  in  the  urine.  If  the  bacteria  come  from  the  kidneys,  an 
occurrence  which  I  have  repeatedly  seen,  then  the  employment  of  sub- 
limate irrigations  is  manifestly  irrational.  In  such  cases  we  must  limit 
our  therapy  to  the  internal  administration  of  urotropin. 

Instillations  of  bichloride,  as  well  as  of  silver  nitrate,  have  often  been 
recommended  for  general  diffuse  cystitis.  This  is  the  same  method 
we  referred  to  under  the  treatment  of  gonorrhoea,  a  few  drops  of  a  2  per 
cent  silver  solution,  or  a  1  :iooo  bichloride  solution,  being  instilled  into 


CYSTITIS.  225 

the  fundus  of  the  bladder.  I  have  seen  good  results  from  this  method 
only  when  the  inflammation  was  localized  to  the  fundus,  that  is,  in 
cases  of  tuberculous  and  gonorrhceal  cystitis.  In  all  forms  in  which 
the  body  of  the  bladder  is  involved — and  it  soon  becomes  affected  in 
gonorrhceal  cystitis — I  recommend  irrigations  instead  of  instillations. 

As  already  stated  there  are  few  cases  of  cystitis  which  do  not  im- 
prove under  rationally  conducted  irrigation.  Even  the  severe  catarrh 
of  long  duration  which  is  associated  with  diverticula  of  the  bladder 
becomes  less.  If  a  case  proves  exceptionally  obstinate  and  the  usual 
measures  do  not  succeed,  then  I  advise  that  a  soft  catheter  be  fastened 
into  the  bladder  and  the  viscus  irrigated  every  one  or  two  hours,  one 
irrigation  with  400  c.c.  [13  fluid  ounces]  of  silver  solution  being  given 
once  during  the  day,  and  boric  acid,  mercury  oxycyanate,  or  merely 
sterile  water  being  used  for  the  others.  More  frequent  use  of  the  silver 
is  too  irritating.  This  treatment  is  extraordinarily  effective.  Unfor- 
tunately, though,  the  patients  often  do  not  bear  the  catheter  well;  it 
causes  them  pain  and  they  desire  its  removal.  The  administration  of 
morphine  during  its  retention  may  serve  to  make  it  tolerable.  Some  in- 
structions concerning  this  permanent  catheter  may  not  come  amiss. 
Its  outer  end  should  be  placed  in  a  vessel  containing  5  per  cent  car- 
bolic acid  or  1  per  cent  bichloride,  so  that  the  urine  may  be  disinfected 
and  new  infection  prevented  from  taking  place  from  without.  This 
is  the  more  important  because  whenever  a  catheter  is  allowed  to  re- 
main in  the  urethra  for  any  length  of  time  urethritis  develops.  Pezzer's 
catheter,  or  the  self-retaining  catheter  designed  by  me,  are  appropriate 
instruments  for  use.  In  treating  old,  debilitated  men  care  should  be 
taken  to  have  the  upper  part  of  the  body  raised  as  high  as  possible,  so 
as  to  guard  as  much  as  possible  against  the  development  of  hypostasis. 

In  case  all  of  these  measures — the  hygienic,  the  internal,  and  the 
local — do  not  succeed,  then  we  possess  as  a  last  expedient  certain 
operative  procedures.  These  consist  either  in  opening  the  bladder 
and  draining  it  for  awhile,  or  in  addition  thereto  in  curetting  the 
mucous  membrane. 

Formerly  the  practice  of  rapidly  dilating  the  sphincter  of  the  bladder 
in  the  female  by  means  of  Simon's  speculum  was  thought  well  of  for 
the  purpose  of  securing  drainage.  I  have  never  seen  any  great  advan- 
tage result  from  this  procedure,  and,  moreover,  think  that  there  is  danger 
of  its  producing  incontinence  of  urine. 

In  the  female  the  bladder  is  now  drained  by  a  colpocystotomy,  the 


226  DISEASES    OF    THE    URINARY    BLADDER. 

mucous  membrane  of  the  bladder  and  vagina  being  sutured  together 
so  as  to  establish  a  fistula,  through  which  a  permanent  catheter  is  intro- 
duced and  the  bladder  energetically  irrigated. 

In  man  either  the  boutonniere  opening  (external  urethrotomy)  is 
made  or  suprapubic  cystotomy  performed.  A  catheter  is  fastened  into 
the  wound  and  the  bladder  washed  out  with  the  medicated  fluids  already 
mentioned. 

As  to  curettage  it  can  be  performed  in  the  female  through  the  urethra 
without  opening  the  bladder.  In  the  male  either  a  suprapubic  or  per- 
ineal cystotomy  has  to  be  done.  The  bladder,  chiefly  in  the  region  of 
the  neck  and  fundus,  is  freed  from  its  fungosities  by  scraping  with  the 
curette.  It  is  only  when  a  suprapubic  opening  is  made  that  the  other 
parts  of  the  bladder  are  accessible;  the  posterior  wall  cannot  safely 
be  reached  through  a  perineal  incision  nor  through  the  female 
urethra. 

My  opinion  of  these  various  procedures  is  that  in  the  most  exceptional 
cases  drainage  may  be  indicated.  In  man  it  should  be  made  through 
the  perineum,  in  woman  through  the  vagina.  A  suprapubic  fistula 
drains  the  bladder  badly  because  it  lies  too  high.  These  artificial 
openings  sometimes  give  good  results,  and  are  at  least  not  dangerous. 
The  bladder  can  be  more  thoroughly  cleansed  through  them  than  through 
the  urethra.  Notwithstanding  this,  however,  they  should  be  reserved 
for  the  most  urgent  cases,  as  for  example,  those  which  are  exceedingly 
painful  and  fail  absolutely  to  be  influenced  by  other  measures. 

Curettage  of  the  bladder  has  as  yet  been  too  little  practised  to  per- 
mit it  being  recommended  as  an  assured  method  of  treatment.  Should 
its  performance  be  deemed  advisable  the  suprapubic  route  is  the  one 
of  choice. 

TUBERCULOSIS  OF  THE  BLADDER. 

A  disease  of  extraordinary  importance  and  frequency,  and  one  which 
for  a  long  time  received  too  little  attention,  is  tuberculosis  of  the  bladder. 
Observations  made  within  the  last  five  or  ten  years  have  showed  that 
it  is  much  more  common  than  formerly  was  thought.  A  large  number 
of  the  obscure  so-called  cryptogenetic  cases  of  painful  cystitis  are  in 
reality  tuberculous,  and  their  accurate  recognition  is  important  be- 
cause many  cases  can  be  cured  if  diagnosticated  early,  and  in  others 
the  patient  can  be  materially  benefited  and  his  existence  rendered  tol- 
erable once  the  nature  of  his  malady  is  recognized. 


TUBERCULOSIS    OF    THE    BLADDER.  227 

ETIOLOGY. 

As  to  the  etiology  of  this  disease  it  may  be  stated  that  the  cause 
producing  it  is  the  same  as  that  which  gives  rise  to  tuberculosis  in 
general,  namely,  infection  with  the  tubercle  bacillus.  The  fact  must 
be  emphasized,  however,  that  the  mere  passage  of  tubercle  bacilli 
through  the  bladder  does  not  suffice  to  produce  infection.  To  be  sure, 
there  is  a  form  of  excretory  vesical  tuberculosis  caused  by  the  passage 
of  tubercle  bacilli  through  healthy  kidneys  into  the  bladder.  On  the 
other  hand,  there  are  cases  in  which  the  organisms  pass  from  the  kid- 
neys to  the  bladder  for  considerable  periods  of  time  without  the  latter 
organ  becoming  diseased.  Therefore  it  would  seem  that  the  assump- 
tion of  a  certain  predisposition  to  infection  is  necessary  for  the  explana- 
tion of  the  development  of  this  malady.  We  must  also  refer  again  to  a 
statement  made  in  a  preceding  section  concerning  the  etiology  of 
cystitis,  namely,  that  trauma,  congestion,  and  retention  of  urine  are 
predisposing  factors. 

Another  opinion  prevails  among  strictly  orthodox  bacteriologists, 
according  to  whose  ideas  bacteria  move  with  the  celerity  of  bullets  and, 
like  them,  stop  wherever  they  strike.  To  these  gentlemen  predisposi- 
tion and  exposure  are  synonymous  terms.  In  our  following  consider- 
ation of  tuberculosis  of  the  bladder  we  shall  prove  that  this  theory  is 
not  tenable,  and  shall  show,  moreover,  that  the  development  of  all 
forms  of  the  disease  may  readily  be  explained  by  the  hypothesis  of 
susceptibility  to  infection. 

In  the  first  place  tuberculosis  of  the  bladder  is  a  symptomaticaffection, 
that  is,  it  may  be  a  symptom  of  generalized  tuberculosis;  and  just  here 
it  may  not  be  amiss  to  take  notice  of  the  fact  that  by  choice  tuberculosis 
attacks  more  than  one  organ. 

Tuberculosis  of  the  lungs  is  the  most  common  form  of  the  infection. 
That  the  vesical  form  is  not  more  frequently  observed  in  the  subjects 
of  phthisis  is  due  to  the  fact  that  many  die  before  the  bladder  becomes 
involved,  and  others  have  their  attention  concentrated  upon  their  pul- 
monary symptoms  to  the  exclusion  of  other  manifestations  of  their 
disease.  Yet,  after  all,  such  patients  presenting  vesical  symptoms  are 
not  rare. 

Next  to  tuberculosis  of  the  lungs  tuberculosis  of  the  kidneys  is  the 
form  with  which  vesical  involvement  is  most  frequently  associated.  In 
these  cases  infection  occurs  in  one  of  two  ways :  infectious  material  is 
either  brought  directly  from  the  kidneys  to  the  bladder  through  the 


228  DISEASES    OF    THE    URINARY    BLADDER. 

ureters,  or  else  renal  and  vesical  infection  takes  place  independently 
from  a  primary  focus  in  the  lungs  by  way  of  the  blood  or  lymph-stream. 
In  their  clinical  manifestations  these  forms  differ  essentially  from  one 
another,  as  will  be  shown  later. 

Another  form  of  tuberculosis  of  the  bladder  results  from  tuberculous 
lesions  of  the  genital  organs  unassociated  with  any  other  foci  of  infection. 
Thus,  tuberculous  processes  may  extend  to  the  bladder  directly  from 
the  seminal  vesicle,  the  testicles,  the  epididymis,  or  the  prostate.  This 
form  of  development  is  easily  recognized  because  tuberculous  lesions 
of  the  above  mentioned  organs  are,  as  a  rule,  distinctly  palpable,  the 
seminal  vesicles  being  the  only  structures  not  readily  accessible  to  the 
examining  finger.  Very  often  these  affections  exist  simultaneously 
with  tuberculosis  of  the  lungs. 

In  contradistinction  to  these  more  common  and  generally  recognized 
forms  we  now  come  to  the  consideration  of  primary  tuberculosis  of  the 
bladder,  the  existence  of  which,  however,  is  not  undisputed.  If  the 
existence  of  primary  tuberculosis  of  the  bladder  is  conceded,  it  is  nec- 
essary to  exclude  the  presence  of  any  other  tuberculous  focus  within  the 
body,  a  thing  which  it  will  often  be  exceedingly  difficult,  if  not  actually 
impossible,  to  do. 

Due  weight  must  be  given  to  the  fact  that  a  tuberculous  process  may 
remain  latent  in  certain  organs  for  years  without  producing  the  slightest 
morbid  phenomena.  I  have  known  men  to  suffer  from  ill-defined 
urinary  disorders  for  a  long  time  without  being  able  to  demonstrate 
any  objective  source  of  their  trouble,  until  finally  the  signs  of  vesical 
tuberculosis  manifested  themselves,  and  later  tubercles  of  the  prostate 
developed.  In  these  instances  it  is  probable  that  a  focus  previously 
existed  on  some  part  of  the  prostate  not  accessible  to  palpation.  It 
has  been  a  not  uncommon  experience  with  me  to  have  tuberculosis 
of  the  prostate  run  a  symptomless  course  and  only  be  discovered  after 
it  has  extended  to  the  urinary  tract. 

Doubtless  there  are  cases  also  in  which  the  bladder  is  the  only  organ 
attacked.  Such  cases  I  have  seen  especially  in  women  who  for  years 
presented  no  apparent  abnormality  except  the  lesions  of  the  bladder. 
These  cases  are  not  well  understood  because  we  do  not  know  the 
reason  why  the  tubercle  bacilli,  which  we  believe  are  harbored  by  a 
large  proportion  of  mankind,  take  up  their  abode  in  the  bladder  and 
become  virulent. 

It  is  much  easier  to  offer  a  plausible  explanation  of  those  cases  in 


TUBERCULOSIS  OF  THE  BLADDER.  229 

which  some  cause  can  be  assigned.  Of  such  causes  I  wish  especially 
to  direct  attention  to  gonorrhoea,  because  the  relation  existing  between 
gonorrhoea  and  tuberculosis  is  not  sufficiently  understood.  I  believe 
that  gonorrhoea,  especially  when  it  affects  the  bladder,  acts  similarly 
to  a  traumatism,  and  that  it  prepares  a  favorable  soil  for  the  develop- 
ment of  tuberculosis. 

The  question  also  arises  as  to  whether  infection  of  the  urinary  or 
genital  organs  can  result  from  cohabitation  with  a  tuberculous  person. 
Such  a  case  has  not  yet  been  proved.  Cornet  believes  that  infection 
during  intercourse  more  likely  takes  place  from  without,  and  remarks 
that  the  genitals  are  often  wet  with  spittle  to  facilitate  performance  of 
the  sexual  act.  He  is  of  the  opinion  that  the  bacilli  pass  through  the 
urethra,  which  is  only  slightly  susceptible  to  their  action,  and  take  up 
their  abode  in  the  bladder,  just  as  they  pass  through  the  mouth,  nose,  and 
throat  without  doing  damage  and  yet  disseminate  disease  in  the  lungs. 

PATHOLOGICAL   ANATOMY. 

The  development  of  tuberculosis  in  the  bladder  is  the  same  as  in  any 
other  organ.  In  the  earliest  stage  small  gray  nodules  are  observed, 
some  of  them  being  so  small  that  they  cannot  be  observed  with  the  naked 
eye,  while  the  largest  are  about  the  size  of  a  hemp-seed.  They  are 
more  or  less  numerous  and  occur  either  singly  or  in  masses,  which,  pro- 
jecting over  the  surface  of  the  bladder,  give  it  the  appearance  of  being 
studded  with  follicles.  These  tubercles  are  of  firm  consistence  and 
impart  a  feeling  of  roughness  to  the  finger  when  it  is  passed  over  the 
surface  of  the  bladder. 

In  comparison  with  later  stages  of  the  disease  this  early  stage  is  rarely 
seen  at  autopsy.  In  order  to  illustrate  it  two  plates  are  inserted,  one 
of  which  (Fig.  163),  taken  from  Guterbock's  work,  shows  a  fresh 
eruption  of  tubercles  at  the  ureteral  orifice,  while  the  other  (Figs.  66 
and  67),  taken  from  the  living  subject  by  means  of  intravesical  pho- 
tography, shows  tubercles  in  two  stages  of  evolution. 

As  in  all  other  organs  tubercle  in  the  bladder  undergoes  retrograde 
metamorphosis.  The  center  of  the  gray  nodule  gradually  becomes 
paler  and  more  opaque  and  the  whole  mass  soon  assumes  a  yellowish 
white  color,  a  phenomenon  which  represents  destruction  of  the  cellular 
elements.  The  nuclei  first  shrivel  and  then  disintergrate,  the  proto- 
plasm disappears,  and  the  cell  detritus  gradually  loses  its  color;  flakes 
of  hyaline  material  now  appear,  and  finally  a  tolerably  homogeneous 


230  DISEASES    OF    THE    URINARY    BLADDER. 


Fig.  163. — Fresh  tuberculous  eruption  at  the  ureteral  orifices. 


TUBERCULOSIS    OF    THE    BLADDER.  23 1 

mass  is  formed  containing  a  variable  number  of  fat  cells,  which  impart 
the  opaque  yellowish  white  appearance  above  mentioned. 

Later  complete  softening  of  the  tubercle  takes  place,  the  destroyed 
cellular  elements  being  converted  into  a  thick,  slimy,  caseous  mass. 
If  this  process  of  softening  extends  to  the  surface,  the  cheesy  masses 
become  partly  excavated  and  a  tuberculous  ulcer  results.  If  the  areas 
of  softening  are  small  the  ulcers  are  small  and  localized,  whereas  if 
several  areas  coalesce  large  ulcers  with  irregular  borders  are  formed. 

Ulcers  the  size  of  a  three-mark  piece  are  sometimes  observed. 
These  are  generally  superficial,  although  at  times  they  invade  the  mus- 
cular coat  of  the  bladder  and  even  extend  beyond  it. 

When  the  disease  has  made  such  inroads  as  this,  and  generally  even 
much  earlier  in  its  progress,  changes  in  the  mucous  membrane  of  the 
bladder  take  place  which  lead  to  the  development  of  a  tuberculous 
cystitis.  Inflammatory  areas  not  differing  from  those  seen  in  other 
forms  of  cystitis  develop  around  the  tubercles.  The  surface  of  the 
bladder  is  discolored,  varying  from  gray  to  red  in  hue,  is  well  vascular- 
ized in  places  and  may  even  present  areas  of  ecchymosis.  On  the 
whole  the  mucous  membrane  of  the  bladder,  which  is  infiltrated  with 
blood  and  sanguinopurulent  mucus,  appears  swollen,  ulcerated,  thick- 
ened, and  covered  with  a  layer  of  pus. 

In  advanced  cases  the  morbid  process  generally  penetrates  to  the 
deeper  layers.  When  this  occurs  the  musculature  of  the  bladder  is 
thickened  and  contracted,  often  to  such  an  extent  that  the  organ  is  no 
larger  than  an  egg.  The  prevesical  tissue  is  also  occasionally  involved, 
and  becomes  changed  into  a  thick  layer  which  is- scarcely  separable 
from  the  bladder  itself.  Very  rarely  a  phlegmon  forms  here;  it  may 
rupture  into  the  rectum  or  vagina,  break  into  the  perineum,  or  discharge 
its  contents  into  the  space  of  Retzius.  Such  a  condition  may  leave 
fistulous  tracts  after  partial  repair  has  taken  place. 

These  different  stages  of  tuberculosis,  together  with  the  various 
lesions,  namely,  gray  tubercles,  yellow  tubercles,  minute  areas  of  soften- 
ing, large  confluent  ulcerations,  and  secondary  inflammation  of  the 
mucosa  and  muscularis,  are  occasionally  observed  together  at  autopsy, 
but  more  commonly  death  comes  earlier  in  the  disease  from  some  in- 
tercurrent affection  and  only  a  few  of  these  pathic  changes  are  seen. 
Thus,  merely  isolated  tubercles  may  be  observed,  or  tubercles  and  ulcer- 
ations, ulcerations  and  areas  of  inflammation,  may  be  present  side  by 
side. 


232  DISEASES    OF    THE    URINARY    BLADDER. 

From  a  clinical  standpoint  it  is  of  great  importance  to  determine  the 
exact  localization  of  these  lesions. 

In  the  descending  form  of  the  disease  minute  tubercles  will  be  found 
in  the  region  of  the  urethral  orifice,  occurring  on  a  line  which  corresponds 
to  the  direction  in  which  the  urine  is  discharged  from  the  ureters. 
Small  ulcers  may  also  be  recognized  here.  All  in  all,  however,  the  mor- 
bid process  in  this  form  of  the  malady  is  not  much  advanced ;  the  lesions 
are  apt  to  be  localized  and  the  bladder  as  a  whole  is  not  much  impaired. 

If  this  descending  form  exists  in  the  bladder  for  a  long  time,  then,  of 
course,  the  above  depicted  condition  becomes  converted  into  one  of 
general  vesical  tuberculosis,  or  more  correctly  speaking,  into  tuberculous 
cystitis.  The  trigonum  of  Lieutaud,  that  is,  the  area  between  the 
urethral  opening  and  the  neck  of  the  bladder,  is  the  seat  of 
predilection  for  the  alterations,  though  an  eruption  of  tubercles  may 
occur  on  the  lateral  walls,  on  the  anterior  wall,  or  upon  the  summit 
of  the  bladder.  In  such  cases  tuberculous  ulcers  surrounded  by  an 
inflammatory  zone,  and  also  a  suppurating  lardaccous  coating  on 
the  base  of  the  bladder,  are  found  to  be  associated  with  the  growth 
of  tubercles. 

The  disease  often  extends  from  the  bladder  to  neighboring  parts, 
such  as  the  posterior  urethra,  the  ureters,  and  the  pelvis  of  the  kidneys. 
It  seldom  or  never  reaches  the  anterior  urethra,  because  generally  it  is 
so  far  advanced  when  it  invades  the  posterior  urethra  that  it  causes 
rapid  termination  of  life. 

SYMPTOMS,  CLINICAL  COURSE,  AND  DIAGNOSIS. 

In  conformity  with  the  pathologic  division  which  we  have  made 
separating  isolated,  discrete  tuberculous  nodules  unassociated  with 
secondary  inflammatory  phenomena  from  true  tuberculous  cystitis 
with  its  severe  generalized  lesions,  involving  especially  the  base  of  the 
bladder,  we  may  divide  the  clinical  manifestations  of  vesical  tubercu- 
losis into  an  initial  stage  and  a  fully  developed  stage  of  inflammation. 

In  the  initial  stage,  which  we  meet  with  when  the  tuberculous  process 
has  just  begun  to  descend  from  the  kidneys  and  establish  itself  in  the 
ureters,  or  when  during  the  course  of  phthisis  a  few  foci  appear  in  the 
bladder,  or  more  rarely  in  the  beginning  of  primary  vesical  tuberculosis, 
only  two  well-defined  symptoms  are  to  be  observed,  namely,  increased 
frequency  of  micturition  and  haematuria. 

The  frequency  of  urination  is  not  very  great,  but  yet  the  patients  are 


TUBERCULOSIS    OF    THE    BLADDER.  233 

obliged  to  pass  their  water  oftener  during  the  day  than  a  healthy  person, 
and  are  also  forced  to  urinate  in  the  night.  Micturition  is  not  really 
painful,  although  at  the  end  of  the  act  an  uncomfortable  feeling  akin  to 
pain  is  experienced.  This  discomfort  may  be  alleviated  and  at  times 
removed  by  narcotics,  although  the  frequency  of  urination  is  scarcely 
affected  by  their  use. 

While  the  urine  passed  during  this  period  is  usually  clear  there  occurs 
at  times  a  hematuria  which  is  characterized  by  short  duration  and  by 
the  fact  that  it  almost  always  begins  after  micturation.  The  blood, 
however,  may  be  mixed  with  the  urine.  Neither  activity  nor  rest  exerts 
any  influence  whatever  upon  the  haemorrhage,  in  which  respect  it  resem- 
bles that  due  to  tumor  of  the  bladder,  although  the  quantity  of  blood 
lost  is  materially  less  than  in  haemorrhage  due  to  new  growths,  being 
often  so  slight  as  to  be  demonstrable  only  by  means  of  the  microscope. 

If  the  vesical  tuberculosis  thus  developing  from  single  circumscribed 
areas  produces  a  tuberculous  cystitis — and  it  has  been  my  experience 
that  it  does  in  course  of  a  few  months— then  the  aspect  of  the  case  is 
essentially  different. 

In  general  it  may  be  said  that  the  symptoms  of  tuberculous  cystitis 
are  the  same  as  those  of  other  forms,  namely,  strangury,  painful  mic- 
turition, and  the  presence  of  pus  or  blood  in  the  urine;  in  tuberculous 
cystitis,  however,  these  symptoms  are  of  special  significance. 

The  strangury  dominates  the  entire  symptom-complex.  Although 
this  symptom  is  observed  in  numerous  other  diseases  of  the  bladder 
and  kidneys,  it  is  not  so  severe,  so  constant,  so  distressing,  so  little  in- 
fluenced by  treatment  as  in  this  affection.  It  is  in  the  descending  form 
of  the  malady,  in  which  the  process  is  located  at  the  ureteral  orifice, 
that  this  symptom  least  troubles  the  patient.  When  the  disease  advances 
to  the  trigonum  and  comes  nearer  to  the  neck  of  the  bladder  then  the 
pain  becomes  unendurable,  and  though  hot  sitz-baths  and  powerful 
narcotics  afford  transitory  relief  they  produce  no  permanent  effect. 
Repeated  attacks  take  place  in  which  the  patients  are  forced  to  urinate 
every  five  or  ten  minutes. 

Their  torment  is  increased,  moreover,  by  the  pain  which  is  associated 
with  each  and  every  act  of  micturition,  and  which  is  especially  severe 
at  the  end  of  the  act.  If  an  attempt  be  made  to  hold  the  urine  the 
slight  distention  resulting  therefrom  causes  increased  desire  to  urinate; 
if  the  patient  seeks  to  escape  from  this  discomfort  by  voiding  his  water 
the  slight  relief  experienced  during  its  passage  through  the  urethra  is 


234  DISEASES    OF    THE    URINARY    BLADDER. 

followed  by  a  violent  burning  which  localizes  itself  at  the  end  of  the 
penis.  Scarcely  does  this  painful  paroxysm  cease  when  contractions 
of  the  bladder,  together  with  tenesmus  ensue,  giving  rise  to  stinging 
pain  which  extends  even  to  the  rectum.  Often  the  penis  becomes 
turgid,  the  face  suffused  with  blood,  and  the  whole  body  covered  with  a 
cold  sweat.  At  last  the  agony  diminishes,  and  the  patient  becomes 
calm,  although  in  the  intervals  he  is  still  beset  with  a  feeling  of  heavi- 
ness and  burning  which  radiates  to  the  rectum  and  anus. 

It  is  self-evident  that  the  degree  of  pain  does  not  always  reach  the 
height  just  described,  but  that  more  commonly  it  shows  considerable 
diversity  of  gradation.  Whenever  the  patient  sustains  any  injury, 
however,  be  it  increase  of  inflammation  resulting  from  excesses  or  ex- 
posure to  cold,  be  it  traumatism  due  to  improper  local  treatment, 
then  the  above  depicted  lamentable  condition  almost  always  super- 
venes. 

We  now  come  to  the  consideration  of  the  third  symptom,  the 
presence  of  pus  and  blood  in  the  urine ;  and  in  regard  to  the  char- 
acter of  the  urine  I  desire  to  state  that  although  it  is  acid  in  the 
majority  of  cases  of  cystitis,  in  tuberculous  cystitis  it  rarely  possesses 
this  property. 

The  amount  of  pus  varies  greatly,  being  dependent  upon  the  extent 
and  intensity  of  the  disease.  As  a  rule  the  quantity  is  much  greater 
than  in  other  forms  of  cystitis.  This  is  due  to  the  fact  that  in 
tuberculous  cystitis  there  is  present  in  addition  to  the  ulcers  and 
tubercles  a  diffuse  inflammation  involving  almost  the  entire  bladder, 
whereas  in  many  other  forms,  as  the  gonorrhceal,  for  example,  the 
morbid  process  is  circumscribed  and  more  closely  confined  to  the 
neck  of  the  bladder.  The  presence  of  a  large  quantity  of  pus  is  not 
of  great  importance,  for  it  occurs  in  other  forms,  as  for  example,  those 
associated  with  paralysis  and  diverticula  of  the  bladder. 

An  occurrence  of  more  gravity  is  admixture  of  blood  with  the 
urine.  While  it  is  true  that  blood  is  found  in  the  urine  in  other  forms 
of  cystitis,  as  for  example,  the  calculous,  and  also  in  gonorrhceal  in- 
flammation of  the  neck  of  the  bladder,  the  onset  and  course  of  these 
affections  distinguish  them  from  tuberculosis.  Moreover,  haemorrhages 
occur  only  rarely  in  these  other  forms,  while  in  tuberculosis  their  occur- 
rence is  the  rule.  Of  course  under  the  term  haemorrhage  are  included 
losses  of  blood  so  slight  as  to  be  demonstrable  only  by  the  microscope. 
In  my  experience  these  minute  haemorrhages  occur  in  almost  every  case 


TUBERCULOSIS  OF  THE  BLADDER.  235 

of  vesical  tuberculosis;  during  exacebations  they  become  more  severe 
and  are  often  apparent  to  the  naked  eye. 

The  albumen-content  of  the  urine  is  in  no  wise  characteristic.  In 
cases  of  simple  tuberculosis  of  the  bladder  without  associated  renal 
disease,  the  quantity  present  depends  upon  the  amount  of  pus  or  blood 
in  the  urine.  If  in  addition  to  the  disease  of  the  bladder  the  kidneys 
also  are  tuberculous  then  there  is  a  greater  quantity  of  albumen  present. 
Thus  it  will  be  understood  that  the  intrinsic  conditions  of  every  case, 
whether  merely  vesical  or  both  vesical  and  renal,  influence  the  produc- 
tion of  albumen,  and  that  the  presence  of  this  substance  is  not  idiocratic 
to  tuberculosis,  and  that  it  is  not  to  be  considered  as  a  special  symptom 
of  the  malady. 

The  discovery  of  tubercle  bacilli  in  the  urine  is  of  decided  sig- 
nificance. A  few  years  ago  I  was  of  the  opinion  that  these  micro- 
organisms were  found  in  only  about  50  per  cent  of  the  cases  of  vesical 
tuberculosis.  As  a  result  of  increased  experience,  however,  I  have 
come  to  the  conclusion  that  with  our  present  methods  of  examination 
they  are  found  in  80  per  cent  of  all  cases. 

The  method  of  examining  for  the  bacilli  is  as  follows:  a  large  quantity 
of  urine,  preferably  the  entire  quantity  voided  in  twenty-four  hours, 
is  collected,  and  a  little  of  the  sediment,  together  with  a  small  quantity 
of  the  urine  itself,  is  taken  and  placed  in  a  small  flask;  the  flask  is  well 
shaken  and  the  contents  then  centrifuged  vigorously  from  three  to  five 
minutes.  After  pouring  off  the  supernatant  fluid  a  little  of  the  sediment 
is  spread  upon  a  slide,  stained  with  carbol-fuchsin,  decolorized  with 
3  per  cent  hydrochloric  acid-alcohol  and  then  counterstained  with 
methylene  blue.  If  tubercle  bacilli  are  present  accurate  examination 
will  reveal  them.  Examination  is  not  a  matter  of  a  few  minutes,  but 
often  requires  a  half  hour. 

In  case  only  the  red,  acid-fast,  slightly  curved  rods  are  found,  there 
arises,  in  the  opinion  of  many  at  least,  the  question  whether  they  are 
really  tubercle  bacilli,  and  not  smegma  bacilli,  with  which  the  former 
organism  may  readily  be  confounded.  We  must  confess  that  in 
reality  this  difficulty  does  not  exist.  In  the  first  place  the  tubercle 
bacillus  has  a  different  appearance  than  the  smegma  bacillus,  the  latter 
organism  being  almost  always  thicker  than  the  former,  although  it 
must  be  admitted  that  there  are  thick  tubercle  bacilli.  The  smegma 
bacillus  is  not  of  such  a  bright  red  color  as  the  tubercle  bacillus,  which 
tends  to  prove  that  the  former  organism  parts  with  some  of  the  red 


236  DISEASES    OF    THE    URINARY    BLADDER. 

stain  when  subjected  to  the  action  of  acid  and  afterward  takes  up 
some  of  the  blue  stain;  in  fact  smegma  bacilli  are  almost  always 
bluish  red. 

Moreover,  the  smegma  bacilli  are  scattered  throughout  the  whole 
field,  while  the  tubercle  bacilli  appear  thickly  grouped  in  either  small 
or  large  clusters,  and  it  frequently  will  require  an  examination  of  several 
different  fields  before  they  can  be  found.  The  smegma  bacilli  are 
symmetrical  thick  rods,  the  tubercle  bacilli  as  found  in  the  urine  are 
generally  fringed  or  fibrillated,  a  condition  produced  by  the  action  of 
the  urine. 

It  is  an  erroneous  belief  that  the  use  of  absolute  alcohol  affords  a 
means  of  differentiating  the  two  organisms.  I  have  subjected  smegma 
bacilli  to  the  action  of  this  substance  for  fifteen  minutes  or  longer  with- 
out observing  any  more  loss  of  color  to  result  therefrom  than  in  case  of 
tubercle  bacilli.  A  very  valuable  point  of  differentation  is  the  fact  that 
the  smegma  bacillus  is  invariably  associated  with  other  organisms, 
whilst  the  tubercle  bacillus  generally  is  found  by  itself. 

Further  investigation  has  proved  that  culture  methods  do  not  con- 
stitute a  reliable  means  of  differentiating  the  organisms.  Karl  Fraenkel 
has  shown  that  the  microorganisms  cultivated  by  Lazer  and  Czaplewski 
and  thought  by  them  to  be  smegma  bacilli  were  in  reality  pseudodiph- 
theria  bacilli,  organisms  which  almost  always  are  present  in  smegma. 
He  states  that  culture  of  the  true  smegma  bacillus  has  not  yet  been 
successful. 

Owing  to  the  ever-present  possibility  of  mistaking  the  one  organism 
for  the  other,  it  is  desirable  that  the  specimen  of  urine  be  drawn  with 
the  catheter  in  order  to  prevent  contamination  with  smegma.  Even 
after  this  precaution  has  been  taken  there  still  remains  the  possibility 
of  contamination  by  migration  of  the  smegma  bacillus  to  the  bladder, 
although  such  an  occurrence  is  hardly  probable,  for  if  it  were,  we  cer- 
tainly would  find  the  organism  in  the  urine  of  healthy  persons,  or  in 
that  of  patients  suffering  with  other  maladies,  much  more  frequently 
than  is  the  case. 

Finally  it  may  be  stated  that  when  a  person  shows  the  symptoms  of 
vesical  tuberculosis  and  acid  fast  bacilli  are  found  in  the  urine,  it  is 
presumptuous  to  call  them  smegma  bacilli.  The  correctness  of  this 
statement  will  become  more  apparent  if  it  be  borne  in  mind  that  smegma 
bacilli  are  sometimes  found  in  the  urine  of  those  who  show  no  vesical 
symptoms. 


TUBERCULOSIS  OF  THE  BLADDER.  237 

Therefore  whenever  acid  fast  bacilli  are  found  I  believe  the  decision 
easy  to  make.  Much  more  difficult  to  determine  are  those  cases  in 
which,  despite  repeated  careful  examination,  no  such  organisms  are 
revealed.  When  dealing  with  such  cases  it  must  be  remembered  that 
the  absence  of  all  bacteria  from  the  urine  of  cystitis  is  highly  suspicious. 
We  have  already  said  that  in  the  presence  of  tubercle  bacilli  other 
organisms  are  usually  absent.  Tuberculous  urine  in  which  no  tubercle 
bacilli  are  present  may  only  be  recognized  by  the  fact  that  often, 
though  not  always,  no  other  organisms  whatsoever  are  contained  in 
it.  Here  the  same  rule  which  obtains  in  the  case  of  pleural  effusion  is 
to  be  followed,  that  is,  if  no  tubercle  bacilli  nor  other  microorganisms 
are  present,  it  is  generally  tuberculous. 

Such  a  finding  should  always  arouse  suspicion  and  lead  us  to  employ 
still  another  means  of  elucidation,  namely,  inoculation,  which  may 
be  made  either  in  the  anterior  chamber  of  a  rabbit's  eye,  or  better  still, 
because  of  the  panophthalmia  which  this  method  may  produce,  into 
the  peritoneal  cavity  of  a  guinea  pig,  the  centrifuged  sediment  being 
injected  with  a  small  syringe  after  the  skin  of  the  abdomen  has  been 
carefully  washed. 

If  the  result  is  positive  there  is  no  cause  for  doubting  the  nature  of 
the  injected  pus;  if  it  is  negative  the  possibility  of  tuberculosis  is  by  no 
means  excluded,  for  sometimes  the  inoculation  does  not  take,  and  then 
again  the  bladder- wall  may  be  tuberculous  and  yet  no  bacilli  be  passed 
in  the  urine.  I  have  with  the  utmost  certainty  pronounced  cases  to  be 
tuberculosis  in  which  no  tubercle  bacilli  were  found  in  the  urine  and 
in  which  inoculation  was  negative,  and  have  seen  the  course  of  the  case 
verify  the  correctness  of  my  diagnosis. 

This  certainty  of  diagnosis  may  be  attained  if  a  few  facts  which  clin- 
ical observation  and  our  present  highly  perfected  methods  of  research 
teach  us  be  borne  in  mind. 

It  is  to  be  remembered  that,  in  contradistinction  to  other  forms  of 
cystitis,  often  no  cause  for  the  inception  of  the  malady  can  be  assigned. 

Gonorrhoea,  calculus,  tumors,  foreign  bodies  in  the  bladder,  stricture 
of  the  urethra — any  of  these  may  offer  plausible  explanation  for  the 
development  of  inflammation;  but  tuberculosis  of  the  bladder  generally 
exists  without  us  being  able  to  impute  its  development  to  any  causative 
factors,  and, indeed,  its  insidious  onset  must  be  considered  as  of  consider- 
able diagnostic  value. 

Excessive  tenderness  of  the  bladder  is  one  of  the  characteristic 


238  DISEASES    OF    THE    URINARY    BLADDER. 

features  of  tuberculous  cystitis.  Palpation  through  the  vagina*  in 
the  female,  and  through  the  rectum  in  the  male,  is  painful,  and  if  the 
viscus  be  disturbed  by  the  energetic  use  of  metal  instruments  the  pain 
becomes  unbearable.  Flexible  instruments  are  tolerated  if  used 
gently,  but  sounding  with  hard  catheters  or  touching  the  wall  of  the 
bladder  gives  rise  to  great  pain  and  even  to  vesical  spasm. 

Not  less  significant  is  intolerance  of  the  bladder  to  distenlion. 
When  discussing  the  pathological  anatomy  we  stated  that  in  many 
cases,  and  especially  in  advanced  ones,  the  morbid  process  extended 
deep  into  the  bladder-wall  and  caused  thickening  and  rigidity,  thus 
rendering  any  considerable  degree  of  distention  impossible.  If  an 
attempt  be  made  to  distend  the  organ  by  the  injection  of  fluid, 
haemorrhage  and  intense  pain  are  produced,  which  last  for  days. 

The  lessened  capacity  of  the  bladder  does  not  always  depend  upon 
contraction  of  the  organ,  but  is  often  due  to  vesical  spasm,  which  in 
turn  is  produced  by  inflammation  of  the  vesical  mucous  membrane. 
The  membrane  being  swollen,  and  having  lost  its  elasticity,  cannot 
expand  when  the  bladder  becomes  distended.  That  this  is  true  is 
shown  by  the  fact  that  many  persons,  thus  affected  improve  and  occa- 
sionally regain  the  normal  capacity  of  the  bladder. 

This  state  of  vesical  spasm  does  not  necessarily  mean  that  the  whole 
vesical  mucous  membrane  is  diseased,  for  if  a  single  area  be  affected 
this  alone  may  suffice  for  its  production.  Thus,  diminution  in  capacity 
occurs  in  the  descending  renal  form,  in  which  often  only  the  region 
around  the  ureteral  orifice  is  affected.  The  contracted  or  cicatricial 
bladder,  which  is  incurable  and  generally  not  even  susceptible  to 
palliation,  develops  more  rapidly  in  those  cases  which  are  due  to 
extension  of  disease  from  the  neighboring  sexual  organs  or  in  which 
tubercles   develop   primarily  in   the   bladder. 

In  regard  to  treatment  it  is  of  great  importance  to  distinguish  these 
two  principal  forms,  and  for  this  purpose  the  cystoscope  renders 
valuable  service. 

In  general,  tuberculosis  of  the  bladder  does  not  present  a  specific 
cystoscopic  picture:  besides  diffuse  swelling  and  redness  there  are 
observed  at  times  deeply  congested  localized  areas  clearly  separated 
from  apparently  healthy  tissue,  while  again  ulcerations  which,  however, 
have  nothing  distinctive  about  them,  are  seen;  tubercles  are  very  seldom 
found.  From  this  description  it  will  be  seen  that,  as  just  stated,  there 
is  little  characteristic  in  the  picture,  although  of  course  exceptions  do 


TUBERCULOSIS    OF    THE    BLADDER.  239 

occur;  nevertheless  the  location  of  the  morbid  changes  as  revealed 
by  the  cystoscope  gives  us  information  concerning  the  nature  of  the 
infection.  Thus,  while  the  morbid  process  in  primary  cases  shows 
an  affinity  for  the  posterior  wall  of  the  bladder,  and  in  those  cases  due 
to  infection  from  the  genitalia  extends  from  the  fundus  well  up  toward 
the  sphincter,  and  involves  in  greater  or  less  degree  the  lateral  walls 
as  well,  the  descending  form  confines  itself  to  the  region  of  the  ureteral 
orifice.  In  many  of  my  cases  I  have  observed  ulcerations  in  a 
region  corresponding  to  a  continuation  of  the  course  of  the  ureters. 
In  others  I  found  tubercles  below  the  ureters  toward  the  sphincter, 
and  finally  I  saw  that  which  I  consider  to  be  especially  typical, 
namely,  a.  bullous  oedema  around  the  orifice  of  the  ureter,  there  being 
present  small  translucent  vesicles  which  often  so  encroach  upon  the 
ureter  that  its  orifice  is  apparent  only  when  contractions  take  place, 
or  more  commonly  is  totally  concealed. 

These  differences,  however,  can  be  made  out  only  when  the  disease 
is  in  its  beginning;  when  it  is  at  all  advanced  they  become  more  and 
more  merged  with   one  another. 

When  the  diagnosis  has  already  been  determined  cystoscopy  should 
not  be  resorted  to,  for  it  necessitates  distention  of  the  bladder,  which 
is  very  painful  and  at  times  even  injurious.  Its  injudicious  employ- 
ment may  produce  a  temporary  exacerbation,  or  even  give  rise  to 
extension  of  the  disease. 

While  this  permanent  lessening  of  vesical  distensibility  in  chronic 
cases  is  suspicious,  further  and  valuable  information  as  to  the  nature 
of  the  malady  may  be  derived  by  watching  the  effects  of  treatment; 
for  those  cases  which  present  the  symptoms  of  tuberculosis,  but  in 
which  no  tubercle  bacilli  are  found — concerning  which  the  French 
are  wont  to  say,  "Ms  senlent  la  tuberculose" — are  highly  suspicious 
if  they  do  not  improve,  or  even  grow  worse,  under  the  therapeutic  regi- 
men usually  applied  to  cystitis. 

With  the  exception  of  malignant  forms,  which  are  complicated 
with  tumor  formation,  nearly  all  cases  of  cystitis,  including  those 
occurring  in  the  aged,  are  benefited  by  appropriate  irrigations;  even 
in  those  due  to  diverticula  of  the  bladder,  in  which  the  numerous 
pockets  and  duplications  within  the  organ  are  filled  with  thick,  ropy 
pus,  the  urine  becomes  somewhat  clearer  under  irrigation  treatment. 
If  improvement  does  follow  such  treatment,  or  if  the  condition  becomes 
worse — and  we  very  often  see  cystitis  aggravated  by  nitrate  of  silver 


240  DISEASES    OF    THE    URINARY    BLADDER. 

irrigations — it  has  long  been  my  custom  to  consider  the  case  not  as 
one  of  simple  cystitis,  but  either  as  cystitis  complicated  with  pyone- 
phrosis or  as  tuberculosis. 

As  the  former  condition  can  almost  invariably  be  diagnosticated 
by  means  of  ureteral  catherization,  we  gain  a  diagnostic  point  in  the 
manner  above  described  ex  juvantibus.  Our  diagnosis  may  be  con- 
firmed by  application  of  the  specific  therapeutic  measure  about  to  be 
mentioned,  because  it  is  almost  invariably  the  case  that  vesical  tuber- 
culosis is  benefited  by  these  measures  after  having  failed  to  yield 
to  the  remedies  used  in  the  treatment  of  simple  cystitis. 

After  all  I  believe  that  the  diagnosis  of  tuberculosis  of  the  bladder 
will  not  be  very  difficult.  If  it  be  borne  in  mind  that  it  occurs  much 
more  frequently  than  was  formerly  thought;  that  an  assignable  cause 
for  its  existence  is  often  wanting;  that  the  symptoms  of  cystitis,  namely, 
strangury,  pain  and  admixture  of  pus  and  blood  in  the  urine  are  present 
in  intensified  degree;  that  an  enormous  thickening  of  the  bladder  with 
resulting  diminution  in  its  capacity  occurs ; — if  these  facts  be  remem- 
bered, I  say,  and  if  to  them  be  added  the  equally  important  one  that  the 
ordinary  therapy  of  cystitis  is  often  totally  ineffective,  or  even  aggra- 
vates the  symptoms,  the  diagnosis  of  tuberculosis  can  be  correctly  made 
whether  tubercle  bacilli  are  or  are  not  found. 

TREATMENT. 

In  order  to  employ  a  fruitful,  or  at  least  a  reasonably  satisfactory 
therapy,  in  tuberculosis  of  the  bladder,  it  is  indispensable  for  the  physi- 
cian to  possess  knowledge  of  the  nature  of  the  malady,  its  extent, 
dissemination,  and  relation  to  other  organs  of  the  body. 

If  the  patient  has  a  unilateral  renal  tuberculosis,  as  a  result  of  which 
the  bladder  has  become  infected,  it  is  evident  that  we  must  attack  the 
root  of  the  evil  and  remove  the  diseased  kidney.  Experience  has 
taught  that  even  severe  tuberculous  disease  of  the  bladder,  when  of 
the  descending  form,  is  benefited  and  even  completely  cured  by  removal 
of  the  primary  tuberculous  focus.  It  is  often  not  necessary  to  treat 
the  vesical  lesion  at  all,  for  it  heals  of  itself  after  the  operation  on  the 
kidney. 

This  preliminary  statement  will  be  obvious  to  every  scientific  physi- 
cian without  further  elucidation,  so  we  may  now  proceed  to  a  dis- 
cussion of  the  ends  to  be  sought  in  the  treatment  of  vesical  tuberculosis, 
and  the  means  by  which  these  ends  are  to  be  accomplished. 


TUBERCULOSIS  OF  THE  BLADDER.  241 

Our  task  is  a  two-fold  one,  varying  with  the  condition  of  the  patient; 
it  consists  either  in  restoring  him  to  health,  or,  if  this  be  impossible 
owing  to  the  severity  of  his  condition,  in  ameliorating  his  suffering 
and  conserving  his  strength. 

Take  for  example  a  person  suffering  from  phthisis  who  becomes 
infected  with  a  vesical  tuberculosis  of  such  intensity  as  to  overshadow 
the  pulmonary  symptoms  because  of  the  strangury  and  painful  mic- 
turition it  produces.  In  such  a  case  cure  of  the  vesical  lesion  is  out 
of  the  question,  but  yet  we  must  make  the  diseased  bladder  the  object 
of  our  therapeutic  effort. 

In  general  it  may  be  stated  that  we  possess  four  measures  for  the 
fulfillment  of  our  task;  namely,  a  hygienic-dietetic  regiiren,  internal 
medication,  local  applications,  and  operative  proi  edures.  A 
combination  of  these  methods  is  often  resorted  to. 

As  we  have  already  stated,  in  a  large  number  of  cases  tuberculosis 
of  the  bladder  is  associated  with  tuberculous  infection  of  other  organs, 
and  even  when  this  is  not  the  case  the  vesical  disease  itself  exposes 
the  patient  to  the  danger  of  further  infection;  therefore  it  is  self-evident 
that  in  every  case  a  roborant,  supporting,  dietetic-hygienic  treat- 
ment identical  with  that  employed  in  other  forms  of  tuberculosis  is 
indicated. 

In  regard  to  these  measures  it  will  suffice  to  say  that  they  are  of  the 
utmost  importance,  and  that  I  have  seen  many  patients,  some  of 
whom  showed  signs  of  tuberculous  disease  of  other  organs,  materially 
benefited  by  several  years  residence  in  a  southern  climate,  such  as 
that  of  Italy  and  Egypt.  In  none  of  these  cases  did  the  urine  become 
entirely  free  from  pus,  but  the  subjective  symptoms — violent  tenesmus 
and  painful  micturition — became  much  lessened  under  the  influence 
of  the  warm  climate. 

Warmth  in  the  form  of  baths  or  compresses  likewise  does  these 
patients  good,  and  affords  us  a  valuable  agent  in  overcoming  tensemus, 
pain,  vesical  spasm,  and  especially  the  acute  exacerbations  of  the 
malady.  I  order  hot  sitz-baths  to  be  taken  several  times  a  day,  having 
the  patient  sit  in  water  of  350  C.  [93°  F.]  and  gradually  increasing  the 
temperature  to  40°  C.  [1020  F.]  or  higher  by  the  addition  of  hot  water. 
As  a  rule  the  bath  is  to  be  made  as  hot  as  the  patient  can  endure,  pro- 
vided of  course  that  no  contraindication  be  present.  These  local 
baths  are  well  borne  by  nearly  all  patients,  and  generally  produce 
great  relief. 
16 


242  DISEASES    OF    THE    URINARY    BLADDER. 

At  night  I  have  a  thermophore  [hot-water  bag]  put  over  the  supra- 
pubic region  and  fastened  by  a  bandage.  In  many  cases  its  action 
is  beneficial.  In  short,  warmth  may  be  applied  in  every  conceivable 
form. 

As  to  internal  medication  three  classes  of  drugs  deserve  our 
consideration;  namely,  tonics,  sedatives,  and  those  which  are 
reputed  to  exert  a  beneficial  effect  upon  the  tuberculous  process. 

The  tonics  employed  are  the  same  as  those  used  in  all  forms  of 
debility:  quinine,  iron,  arsenic,  etc. 

Of  the  sedatives  I  prefer  morphine  above  all  others  as  being 
the  most  rehable  and  certain.  I  place  great  value  upon  this  drug 
because  it  rot  only  quiets  pain,-  but  also  actually  exerts  a  curative 
effect  upon  the  diseased  bladder,  a  fact  which  I  here  desire  to  empha- 
size. A  h .adder  which  is  exceedingly  sensitive  and  in  a  condition  of 
the  greatest  irritability  must  be  quieted  as  much  as  possible,  for  the 
incessant  contractions  resulting  from  such  a  state  constitute  a  great 
hindrance  to  the  relief  of  inflammation;  as  morphine  controls  these 
conditions  the  really  wonderful  results  sometimes  obtained  by  its  use 
are  easily  explained.  It  should  be  administered  freely,  the  dose  being 
determined  by  the  needs  of  the  individual  case.  Subcutaneous  injec- 
tions of  o.oi  to  0.05  [approximately  <j  to  f  grain]  are  the  most  effectual. 
Next  in  value  are  suppositories,  in  which  form  the  dose  should  not  be 
less  than  0.015  [4  grain].  In  selected  cases  heroin  may  be  used  instead 
of  morphine.  Powders  or  pills  containing  from  0.004  to  0.006  [y^  to 
yV  grain]  given  several  times  daily  render  good  service. 

Next  to  these  preparations  belladonna  is  the  most  valuable.  Pills 
or  suppositories  containing  as  much  as  0.05  [about  1  grain]  will  be  found 
especially  useful  if  given  alternately  with  morphine,  and  also  as  a 
substitute  for  morphine  if  it  be  desired  to  discontinue  the  latter  drug. 
Belladonna  possesses  the  special  property  of  diminishing  vesical 
irritability. 

I  cannot  praise  opium  so  highly.  It  does  not  work  so  promptly 
upon  the  bladder  as  upon  the  intestines,  but  yet  we  could  not  always 
dispense  with  it. 

If  we  now  proceed  to  consider  those  remedies  which  are  supposed  to 
exert  a  favorable  influence  upon  the  tuberculous  disease  itself,  I  am  unfor- 
tunately not  able  to  say  much  in  their  favor.  Those  medicaments  which 
render  good  service  in  other  forms  of  cystitis,  as  for  example,  urotropin 
(hexamethylen-tetramin),helmitol,  salol,  camphoric  acid,  and  salicylic 


TUBERCULOSIS  OF  THE  BLADDER.  243 

acid  fail  entirely  in  tuberculosis.  I  have  never  seen  them  produce  any 
effect  worthy  of  mention.  They  are  indicated  only  when  the  micro- 
scope shows  that  organisms  other  than  the  tubercle  bacilli  play  a  role 
in  the  case,  that  is,  when  the  so-called  mixed  infection  manifests  itself. 

The  same  statement  may  be  made  as  to  the  value  of  the  mineral 
waters  which  are  usually  prescribed  for  cystitis.  They  are  not  entirely 
useless  as  they  dilute  the  urine  and  thin  the  pus,  thereby  making  mic- 
turition less  painful.  Vichy,  Salvator,  Wernarz,  or  Obersalzbrunner 
may  be  used. 

Balsamics  are  useless  and  injurious.  Oil  of  sandal- wood  certainly 
has  some  effect  upon  gonorrhceal  cystitis,  but  it  is  utterly  worthless 
in  tuberculous  cystitis,  and,  moreover,  as  it  is  likely  to  disorder  the 
stomach  or  irritate  the  kidneys  I  consider  it  to  be  contraindicated. 

The  only  internal  remedies  which  it  appears  rational  to  administer 
are  creosote,  guaiacol  carbonate,  and  ichthyol.  1  allow  them  to  be 
given  without  restriction  as  to  quantity  for  as  long  a  time  as  the  patients 
tolerate  them.  Ichthyol  is  best  administered  with  water,  as  in  the 
following  prescription: 

1$  Ichthyol  sulpho-ammoniac. 

Aquae  destillatae  aa  30.0  [oj] 

m 

Sig.  Begin  with  10  drops  three  times  a  day  and  increase  gradually  to  half  a 
teaspoonful. 

It  is  still  better  to  give  these  drugs,  which  are  at  best  unpalatable, 
in  the  form  of  oil  injections,  mixing  30  grams  [1  fluid  ounce]  with 
200  grams  [7  fluid  ounces]  of  olive  oil  and  injecting  a  small  glycerine- 
syringeful  into  the  rectum  twice  daily. 

It  is  impossible  to  state  whether  they  exert  a  beneficial  and  curative 
effect  upon  the  disease  itself;  the  most  that  can  be  said  is  that  they 
apparently  do  some  good. 

When  we  come  to  consider  the  local  treatment  of  vesical  tuber- 
culosis the  question  arises  as  to  whether  it  is  altogether  judicious 
to  combine  local  measures  with  general  hygienic  and  internal  treat- 
ment, and  if  so  what  shall  be  the  nature  of  the  same,  in  what  cases 
shall  it  be  applied,  and  what  results  are  to  be  expected  from  it. 

There  are  many  who  would  do  away  with  local  procedures  and 
attempt  to  control  the  often  intolerable  pain  by  means  of  narcotics, 
baths,  and  other  measures. 

My  observations  have  led  me  to  abandon  this  view,  which  I  also 


244  DISEASES    OF    THE    URINARY    BLADDER. 

formerly  held,  -for  I  am  convinced  that  judiciously  conducted  local 
treatment  often  does  great  good,  and  that  it  may  even  effect  a  cure  in 
a  few  cases.  Many  patients  cannot  be  relieved  of  their  suffering 
by  the  most  powerful  narcotics.  In  spite  of  large  doses  of  morphine, 
the  severe  pain  incident  to  urination,  together  with  the  harrowing 
tenesmus  which  forces  the  patients  to  pass  their  urine  every  fifteen 
minutes  or  oftener,  remains  unrelieved. 

To  these  unfortunate  sufferers  local  treatment  is  advantageous; 
though  it  may  not  cure  them  it  will  materially  alleviate  their  distress. 

The  first  principle  of  local  treatment  is  never  to  distend  the  bladder 
by  means  of  irrigations  as  is  done  in  other  forms  of  cystitis.  Guy  on 
goes  so  far  as  to  forbid  flushing  with  a  syringe  or  even  with  an  irrigator, 
permitting  only  the  instillation  of  a  few  drops  of  fluid.  Provided 
that  not  enough  be  injected  to  produce  a  sensation  of  fullness  or  to 
cause  pain,  I  have  found  weak  solutions  to  work  better  and  produce 
a  more  lasting  effect  than  concentrated  instillations.  The  use  of 
soft  instruments  is  recommended,  for  as  already  mentioned  the  tuber- 
culous bladder  is  exceptionally  sensitive  to  metal  instruments. 

Of  the  multitudinous  drugs  which  have  beexi  recommended  for  the  local 
treatment  of  vesical  tuberculosis,  among  which  may  be  mentioned  iodo- 
form, ichthyol,  guaiacol,  and  orthoform,  I  have  seen  only  two,  namely, 
lactic  acid  and  bichloride  of  mercury,  which  produce  any  real 
result ;  nitrate  of  silver,  incontestably  the  best  remedy  in  other  forms  of 
cystitis,  has  a  detrimental  influence  and  increases  the  pain.  This 
observation,  to  which  Guyon  first  called  attention,  was  corroborated 
by  Goldman  and  myself.  Indeed,  it  may  be  said  that,  with  few  excep- 
tions, all  cases  of  cystitis  which  without  apparent  cause  become  worse 
under  silver  treatment  are  most  likely  tuberculous  even  though  no 
tubercle  bacilli  have  been  found. 

Lactic  acid,  which  was  recommended  by  Witzack,  and  which  I 
have  used  in  very  strong  solution  (20%)  in  form  of  instillations,  undoubt- 
edly has  a  good  effect,  but  the  pain  it  produces,  even  though  cocain 
be  used,  is  so  intense  and  lasting  that  I  have  ceased  to  employ  it. 
Indeed,  true  heroism  is  required  to  endure  an  application  of  this  drug! 

I  now  use  bichloride  of  mercury,  a  sovereign  remedy,  for  the  knowl- 
edge of  which  we  are  indebted  to  Guyon.  I  have  tried  it  in  innumer- 
able cases;  in  many  benefit  was  derived,  in  a  few  a  cure,  while  in  some 
no  improvement  was  obtained.  In  the  beginning  I  use  instillations 
of  a  strength  of  from  1 :  iccco  to  1 :  icoo.     As  the  condition  improves, 


TUBERCULOSIS    OF    THE    BLADDER.  245 

as  shown  by  subsidence  of  tenesmus,  less  frequent  micturition,  and 
abatement  of  pain,  I  increase  the  quantity  of  solution,  making  it  weaker 
at  the  same  time,  until  finally  50  cc.  of  a  solution  varying  in  strength 
from  1 :  10000  to  1 :  5000  (seldom  stronger)  are  used.  The  patients 
retain  the  fluid  as  long  as  they  can  without  it  causing  them  great  pain. 
Enough  should  never  be  injected  to  cause  distention  of  the  bladder, 
and  the  application  should  not  be  made  oftener  than  twice  a  week. 

As  the  bichloride  produces  a  painful  reaction,  which  naturally  leads 
patients  to  think  that  their  condition  is  becoming  worse,  it  is  well  to 
warn  them  of  the  primary  effect  of  the  treatment;  or,  as  I  am  in  the 
habit  of  doing,  keep  them  under  morphine  for  the  first  two  days. 
The  dose  of  morphine  required  depends  entirely  upon  the  condition 
of  the  individual  patient. 

[Rovsing,  of  Copenhagen,  has  recently  reported  good  results  from 
the  use  of  carbolic  acid.  After  washing  the  bladder  out  he  injects 
50  cc.  of  a  6  per  cent  solution.  This  is  left  in  the  bladder  for  three 
or  four  minutes.  The  injection  is  repeated  until  the  fluid  returns 
clear.  At  first  the  treatment  is  used  every  two  days,  then  at  longer 
intervals,  and  finally  only  once  in  two  weeks,  three  weeks  and  a  month, 
according  to  the  cystoscopic  appearance  of  the  bladder.  This 
treatment  is  very  painful  at  first,  and  morphia  has  to  be  given  after  it 
is  employed.     Rovsing  gives  it  in  the  form  of  rectal  suppositories.] 

If  it  be  asked  when  and  under  what  circumstances  local  treatment 
should  be  instituted,  the  first  thing  I  desire  to  say  in  answer  is  that  I 
have  never  seen  any  toxic  effects  result  from  the  sublimate  treatment 
administered  as  above  described;  moreover,  one  can  soon  tell  whether 
a  case  is  appropriate  for  the  treatment.  If  sublimate  is  going  to  do 
good  its  effects  will  be  manifest  after  the  first  few  instillations.  If  no 
result  is  experienced  after  three  or  four  applications  the  treatment 
should  be  discontinued. 

The  most  apparent  effect  after  the  reaction  period  is  subsidence 
or  complete  cessation  of  pain.  Strangury  does  not  subside  so  promptly. 
While  micturition  becomes  less  frequent  under  the  influence  of  sub- 
limate treatment  it  is  not  affected  so  quickly  and  regularly  as  is  pain. 
It  will  be  evident,  then,  that  this  treatment  is  especially  indicated  in 
cases  in  which  there  is  persistent,  painful  vesical,  and  also  often  rectal 
tenesmus  which  cannot  be  subdued  by  other  means.  It  is  also  valua- 
ble in  cases  which  have  not  advanced  so  far,  especially  as  painful  after- 
effects do  not  occur  in  this  class  of  cases. 


246  DISEASES    OF    THE    URINARY    BLADDER. 

On  the  other  hand,  it  is  desirable  to  proceed  with  the  greatest  cau- 
tion, endeavoring  to  improve  the  general  condition  of  the  exhausted 
and  suffering  patients,  because  local  treatment,  if  not  carefully  con- 
ducted, may  add  to  their  distress.  It  may  be  necessary  to  allow  from 
two  to  four  weeks  to  elapse  between  the  applications. 

No  hesitancy  should  be  shown  in  giving  highly  nutritious  food  and 
also  wine.  The  ill-founded  fear  of  irritating  the  urinary  organs  must 
cede  to  the  great  desideratum  of  improving  the  general  condition  of 
the  patient.  If  this  indication  can  be  fulfilled  material  results  may  be 
expected  from  our  efforts  to  alleviate  or  cure  the  local  disease.  Tuber- 
culosis no  longer  seems  to  be  such  a  malignant  disease  as  it  formerly 
was  thought  to  be;  we  know  that  it  can  be  cured  when  affecting  the 
bladder  the  same  as  it  is  when  affecting  other  organs.  Villard  has 
shown  in  a  most  admirable  work  that  tuberculosis  of  the  genital 
organs  is  relatively  benign  as  long  as  systemic  infection  can  be  pre- 
vented. Series  of  examples  of  cure  are  contained  in  the  literature  of  the 
subject.     (Guyon,  Motz,  et.  al.) 

All  forms  of  local  treatment  except  the  one  above  described  are  to  be 
discarded.  I  refer  especially  to  the  measures  undertaken  by  means 
of  operation  through  the  cystoscope.  Attempts  have  been  made  to 
remove  intravesical  ulcerations  with  the  galvano-cautery  or  with  caus- 
tics. I  consider  such  treatment  not  only  useless,  but  actually  harm- 
ful. Enough  has  already  been  said  concerning  the  sensitiveness  of 
the  bladder  to  show  that  such  extensive  instrumentation  as  is  necessary 
for  the  performance  of  these  manipulations  would  increase  inflam- 
mation and  lead  to  propagation  of  the  tuberculous  process  instead 
of  conducing  to  its  cure.  The  same  is  true  of  iodoform-gauze  tampons. 
If  one  believes  in  the  efficacy  of  iodoform — but  I  have  never  seen 
any  results  from  its  use — it  may  be  employed  as  an  emulsion  injected 
into  the  bladder  through  a  soft  catheter.  For  the  reason  just  stated 
I  strongly  oppose  these  methods  of  treatment. 

[The  Finsen  light  has  been  tried,  but  the  results  obtained  have  been 
entirely  unsatisfactory.  In  some  cases  the  patients  were  made 
worse.] 

Concerning  the  value  of  surgical  procedures  in  the  treatment 
of  tuberculosis  of  the  bladder,  I  can  express  myself  only  with  great 
reserve,  although  series  of  cases  have  been  reported  as  cured  by  oper- 
ation. 

The  operations  consist  in  opening  the  bladder  either  through  the 


TUBERCULOSIS  OF  THE  BLADDER.  247 

perineum  or  above  the  symphysis.  Some  content  themselves  with 
establishing  a  vesical  fistula,  operating  merely  for  the  purpose  of 
relieving  the  distressing  tenesmus  and  draining  the  bladder,  but  others 
practice  curettement  or  cauterization  of  the  vesical  mucous  membrane; 
there  are  still  others  who  are  not  satisfied  with  curetting,  but  practise 
partial  or  complete  ablation  of  the  mucous  membrane. 

What  I  have  learned  from  my  own  experience  and  from  the  work 
and  writings  of  others  does  not  enable  me  to  speak  very  encouragingly 
in  favor  of  operation,  for  judging  therefrom  it  seems  that  the  pros- 
pect of  bringing  about  a  cure  by  means  of  operation  is  very  slight. 
Only  those  cases  in  which  it  is  certain  that  there  are  but  few  localized 
lesions  are  suitable  for  operation.  It  must  always  be  remembered 
that  recurrence  may  take  place,  and  that  even  if  we  succeed  in  arresting 
the  vesical  disease  tuberculous  infection  of  other  parts  of  the  genito- 
urinary   system   is   probable. 

Curettage  of  the  bladder  is  not  out  of  the  question,  but  if  it  be 
resorted  to  care  must  be  taken  lest  the  disease  be  carried  deeper  into 
the  tissues,  or  become  disseminated  and  cause  general  infection.  It 
will  be  necessary  to  gain  further  experience,  as  the  procedure  is  yet 
too  young  to  permit  the  expression  of  a  definitive  conclusion  regarding; 
its  value.  In  selected  cases  which  fail  to  yield  to  other  forms  of 
treatment  it  may  be  justifiable  to  try  it. 

After  cystotomy  fistula  often  persists,  rendering  the  condition  of 
the  patient  highly  uncomfortable  if  not  actually  tormenting.  There- 
fore it  is  better  to  feed  the  patient  on  morphine  than  to  add  to  his 
already  lamentable  condition  a  permanent  tuberculous  fistula. 

After  what  has  been  said  it  becomes  evident  that  operative  pro- 
cedures are  permissible  only  when  it  is  certain  that  the  tuber- 
culous process  is  confined  to  a  few  circumscribed  areas.  Even  in 
this  class  of  cases  exceptions  must  be  made  when  tuberculous  foci 
exist  in  other  organs,  and  also  when  the  vesical  disease  is  dependent 
upon  descending  infection  from  the  kidneys.  In  regard  to  the  last 
class  of  cases  it  has  already  been  stated  that  the  vesical  ulcerations  often 
undergo  spontaneous  healing  or  yield  to  local  treatment  after  extir- 
pation of  the  diseased  kidney. 

In  conclusion  a  few  words  must  be  said  concerning  the  worth  of 
tuberculin.  The  administration  of  this  preparation  in  general  tubercu- 
losis has  undergone  many  fluctuations.  At  first  lauded  to  the  skies, 
it  was  later  abandoned,  only  to  be  recently  received  with  favor  again 


248  DISEASES    OF    THE    URINARY    BLADDER. 

in  certain  quarters.  I  have  treated  a  few  cases  of  vesical  tuberculosis 
with  it,  and  also  have  observed  others  treated  by  some  of  my  colleagues, 
and  as  a  result  of  these  observations,  together  with  a  study  of  the 
literature  of  the  subject,  the  only  conclusion  I  can  derive  is  that  at 
present  we  are  not  in  a  position  to  pronounce  judgment  as  to  its  value. 

Tuberculin  T.  R.  is  the  preparation  used,  it  being  given  in  ascending 
doses  of  from  1  to  1000  milligrammes.  The  injection  is  repeated 
when  the  reaction  subsides,  and  the  dose  is  increased  whenever  the 
quantity  employed  ceases  to  produce  a  reaction.  I  have  never  seen 
any  untoward  effect  from  its  use.  In  some  cases  subjective  ameli- 
oration seems  to  take  place,  in  others  the  same  failure  results  as  was 
experienced  with  the  other  therapeutic  measures  employed.  Some 
clinicians  state  that  they  have  obtained  more  favorable  results  than  I 
have. 

It  is  yet  too  early  to  speak  positively  for  or  against  this  treatment, 
as  the  number  of  careful  observations  thus  far  made  do  not  warrant 
such  a  course. 

I  do  not  consider  it  justifiable  to  condemn  it.  1  mean  that  it  must 
be  cautiously  tested.  A  disease  such  as  vesical  tuberculosis,  which 
produces  intense  pain  and  makes  life  a  burden,  a  disease  over  which, 
it  is  true,  we  do  have  some  but  by  no  means  enough  control,  justifies  an 
effort  to  secure  better  and  more  effectual  remedies,  our  knowledge 
of  which  must  depend  upon  objective  evidence  derived  from  their  use. 

FOREIGN  BODIES  IN  THE  BLADDER. 

It  is  rare  for  foreign  bodies  to  get  into  the  bladder  and  remain  there. 
By  far  the  greater  majority  of  them  are  broken  off  catheters  or  bougies, 
while  next  in  frequency  come  silk  ligatures,  which  either  find  their 
way  from  neighboring  parts  or  are  brought  into  the  bladder  during 
operation. 

Occasionally  an  object  introduced  into  the  urethra  with  erotic 
intent  passes  on  into  the  bladder.  After  injury,  or  rupture  of  an  abscess, 
sequestra  may  get  into  the  bladder,  although  such  an  occurrence  is 
rare.  Finally  gunshot  wounds  sometimes  cany  pieces  of  clothing 
into  the  bladder. 

Although  in  the  beginning  the  bladder  is  very  tolerant- — there  is 
usually  little  pain — inflammation,  difficulty  of  micturition,  and  infection 
soon  develop.  Cystitis  is  almost  inevitable.  The  urine  becomes 
turbid,  in  many  cases  bloody.     The  lesions  produced  depend  upon 


FOREIGN    BODIES    IN    THE    BLADDER.  249 

the  character  of  the  foreign  body,  upon  whether  it  has  a  sharp  point  or 
edges.  In  a  very  short  time  the  urinary  salts  are  deposited  upon  the 
object  and  it  becomes  encrusted  with  phosphates  and  urates. 

The  diagnosis  offers  no  difficulties.  Generally  the  history  will 
reveal  the  trouble.  If  not  we  at  present  possess  a  sovereign  means 
of  diagnosis  in  the  cystoscope.  Formerly  all  kinds  of  sounds  and 
instruments  which  made  a  noise  when  the  foreign  body  was  grasped 
between  their  blades  were  employed.  Today  one  glance  through 
the  cystoscope  enables  us  to  detect  the  presence  of  a  foreign  body 
and  determine  its  nature. 

Metal  objects  are  easily  revealed  by  the  X-ray. 

The  cystoscope  is  also  used  to  facilitate  the  removal  of  foreign 
bodies.  An  attempt  may  be  made  to  seize  the  object  with  the  litho- 
trite,  but  if  it  is  not  successful  it  should  be  abandoned  at  once.  Spon- 
taneous expulsion  of  the  body  must  never  be  reckoned  on. 

It  is  practically  out  of  the  question,  for  as  already  stated  incrustation 
soon  occurs  and  the  object  becomes  so  large  that  it  is  impossible  for 
it  to  pass  through  the  urethra. 

If  the  lithotrite  fails,  the  cystoscopic  forceps,  an  instrument  I  have  had 
made  by  Hirschmann,  should  be  used.  Its  branches  come  asunder  and 
its  shaft  is  hollow  so  that  a  cystoscope  can  be  passed  through  it.  The 
foreign  body  can  usually  be  seen  with  the  greatest  distinctness  and  can 
be  seized  and  drawn  out  under  the  guidance  of  the  eye.  In  this  way 
I  have  repeatedly  removed  catheters,  bougies,  and  threads. 

This  procedure  is  contraindicated  when  the  object  is  firmly  incrusted 
with  salt  and  has  become  so  big  that  there  is  danger  of  its  materially 
injuring  the  urethra.  Suprapubic  cystotomy  then  becomes  the  proper 
procedure,  for  although  it  causes  the  patient  a  greater  loss  of  time, 
it  saves  him  from  permanent  injuries,  such  as  would  follow  the  forcible 
extraction  of  a  large  foreign  body  through  the  urethra.  In  the  latter 
instance  traumatic   stricture   would  be  the  result. 

It  is  not  uncommon  to  meet  with  foreign  bodies  in  the  bladder  of 
persons  who  have  a  narrow  urethra,  because  such  persons  have  to 
have  catheters  or  bougies  passed.  In  such  cases  the  cystoscope 
cannot  be  immediately  resorted  to.  Either  suprapubic  cystotomy 
must  be  performed  and  the  foreign  body  removed  through  the  incision, 
or  the  stricture  dilated  and  the  cystoscope  then  used.  As  the  bladder 
would  be  injured  by  retention  of  the  foreign  body  for  any  length  of 
time  its  early  removal  is  desirable;  therefore  operation  has  to  be  con- 


250  DISEASES    OF    THE    URINARY    BLADDER. 

sidered.  To  expedite  matters  I  have  repeatedly  performed  internal 
urethrotomy  and  then  immediately  removed  the  foreign  body  with 
the  cystoscopic  forceps.  This  procedure  seems  the  more  rational, 
too,  for  the  reason  that  it  always  overcomes  the  stricture,  which  is 
really  the  cause  of  the  trouble.  Whether  internal  or  external  ure- 
throtomy should  be  done  in  a  given  case  is  to  be  determined  by  the 
principles  laid  down  in  the  article  on  stricutre. 

VESICAL  CALCULUS. 

Stone  in  the  bladder  is  a  disease  which  has  been  known  and  studied 
for  hundreds  of  years.  Notwithstanding  this  the  causes  of  its  develop- 
ment are  not  yet  fully  understood.  According  as  the  calculi  descend 
from  the  kidney  and  remain  in  the  bladder,  or  are  themselves  formed 
in  the  bladder,  we  differentiate  between  primary  and  secondary  cal- 
culus. 

Primary  calculi,  composed  of  uric  acid,  oxalate  of  lime,  or  xanthin, 
are  formed  in  the  kidneys  either  because  these  normal  elements  of 
the  urine  are  excreted  in  excess,  or  because  the  capacity  of  the  urine 
for  holding  them  in  solution  has  become  diminished.  For  example, 
the  smaller  the  quantity  of  sodium  chloride  in  the  urine,  the  smaller 
the  amount  of  urates  which  it  will  dissolve  at  a  given  temperature. 
According  to  one  theory  these  primary  stones  develop  only  as  a  result 
of  precipitation  of  salts  caused  by  increased  crystallization,  while  another 
view  is  that  stone  formation  occurs  only  when  a  connecting  member, 
an  animal  frame- work,  so  to  speak,  in  the  form  of  mucus  or  colloid 
substance,  is  present. 

What  cause  is  responsible  for  the  increased  precipitation  of  salts 
is  known  only  empirically-.  It  has  been  assumed  that  in  the  case  of 
uric  acid  stones  there  is  insufficient  combustion  of  the  products  of 
metabolism.  Gout  and  uric  acid  stones  stand  in  close  relation  to 
one  another.  Immoderate  ingestion  of  meat  associated  with  insuffi- 
cient exercise  has  been  regarded  as  a  cause  of  faulty  oxidation. 

Overloading  the  body  with  vegetable  food,  especially  asparagus, 
tomatoes,  celery,  apples,  and  pears  are  said  to  favor  the  formation  of 
oxalate  calculi.  These  are  merely  hypotheses.  We  only  know  that 
heredity  plays  a  role  in  the  evolution  of  vesical  calculi;  that  primary 
stone  is  more  frequent  in  man  than  in  woman ;  that  the  disease  is  espe- 
cially common  in  childern  and  old  people,  being. more  seldom  encoun- 
tered in  persons  of  middle  life.     The  oxalate  stones  are  common  in 


VESICAL    CALCULUS.  25 1 

poor  children,  while  those  composed  of  urates  occur  in  rich  old  persons 
who  are  high  livers. 

There  are  noteworthy  differences  in  regard  to  the  geographical 
distribution  of  this  disease.  It  is  very  frequent  in  Russia,  Asia  Minor, 
the  east  of  England,  northwest  Germany,  Holland,  Hungary,  Persia, 
Egypt,  and  India.  We  must  assume  that  climate  plays  no  role  in  its 
production,  but  that  diet  and  regimen  of  living  are  more  important 
causative  factors.  The  influence  of  meat  diet  in  the  production  of 
urates,  and  vegetable  diet  on  the  formation  of  oxalates  has  already 
been  mentioned.  Nothing  is  known  concerning  the  influence  of 
drinking  water,  although  we  have  knowledge  of  the  effect  of  certain 
wines.  The  heavy  burgundies  favor  the  development  of  urate  stones, 
the  -  sparkling  wines  (champagne)  and  Rhine  wines  predispose  to  the 
formation  of  the  oxalates. 

The  formation  of  secondary  calculi,  those  composed  of  phos- 
phates and  carbonate  of  lime,  is  much  easier  understood.  Their 
evolution  depends  entirely  upon  the  presence  of  catarrh,  or  a  foreign 
body  in  the  bladder.  In  catarrh  mucus,  pus  and  blood  act  as  foreign 
bodies;  upon  them  is  deposited  the  sediment  of  cystitic  urine,  the 
most  common  being  ammonio-magnesium  phosphate  and  carbonate 
and  phosphate  of  lime.  If  the  urine  becomes  alkaline  owing  to  de- 
composition of  urea,  the  pus  assumes  a  thick,  ropy  character  which 
makes  its  expulsion  difficult,  as  it  adheres  firmly  to  the  wall  of  the 
bladder.  It  will  be  readily  understood  that  these  masses  are  especially 
favorable  for  the  reception  of  precipitated  urinary  salts. 

Pus,  mucus,  blood,  and  parasites  (distoma  hematobium)  may  also 
afford  an  opportunity  for  the  precipitation  of  urates.  This  happens 
when  the  urine  is  still  acid.  If  it  subsequently  becomes  alkaline 
phosphates  are  deposited  around  the  nucleus  of  urates.  In  this  manner 
the  formation  of  mixed  calculi  may  be  explained. 

I  do  not  hold  it  as  fully  proved,  however,  that  pure  phosphatic 
stones  develop  in  a  healthy  bladder,  and  that  they  are  the  expression 
of  a  phosphatic  diathesis,  in  the  same  manner  that  urate  stones  have 
their  origin  in  the  uric  acid  diathesis.  The  possibility  of  this  occur- 
rence can  be  conceded  only  as  a  very  rare  exception,  for  I  know  of 
innumerable  cases  of  phosphaturia  of  years  duration  in  which  no  form- 
ation of  calculi  took  place.  It  is  altogether  different  when  phosphatic 
concretions  are  formed  in  a  diseased  renal  pelvis  and  pass  down  into  the 
bladder.    They  may  then  become  encrusted  with  urates  and  phosphates. 


252 


DISEASES    OF    THE    URINARY    BLADDER. 


The  number  of  stones  found  in  the  bladder  varies  exceedingly. 
There  may  be  few  or  many;  more  than  a  hundred  have  been  removed 
from  a  single  individual.  Likewise  they  vary  extraordinarily  as  to 
size,  some  being  as  small  as  a  pea,  others  as  large  as  a  hen's  egg.  The 
larger  the  number  the  smaller,  as  a  rule,  is  the  size  of  the  calculi. 

Their  weight  ranges  from  3  to  60  g.  [45  to  900  grains].  In  shape 
they  are  generally  round  or  oval.  When  many  are  present  their  sur- 
faces are  generally  flat  and  smooth.  Those  composed  of  urates 
are  finely  granular  on  their  upper  surface,  and  have  a  yellow  or  yellow- 
ish-red color.  Those  composed  of  oxalates  are  round,  rough,  and 
provided  with  pointed  projections  and  spines.  This  attribute,  together 
with  their  deep  brown  or  grayish-black  color,  has  given  them  the  name 
of  mulberry  calculi.  Phosphatic  stones,  being  usually  multiple, 
present  several  surfaces;  they  are  smooth  and  of  a  light  gray  color. 

As  to  consistence  the  oxalate  stones  are  the  hardest,  oxalate  of  lime 
being  a  substance  which  it  is  sometimes  impossible  to  crush.  Next 
come  the  urate  calculi,  which  also  may  be  very  hard,  but  which  seldom 
withstand  crushing.  The  phosphatic  stones  are  soft  and  can  be  easily 
reduced  to  powder.  The  rare  cystin  stones  are  soft;  those  composed 
of  xanthin  have  about  the  same  consistence  as  those  formed  of  urates. 

Mixed  stones  present  the  most  multifold  combinations.  They 
are  most  frequently  composed  of  phosphates  with  a  nucleus  of 
urates,  urates  with  an  oxalate  nucleus,  or,  conversely,  oxalate  with  a  urate 
nucleus.  But  irrespective  of  the  nucleus,  which  may  also  be  a  foreign 
body,  such  as  a  needle,  a  thread,  or  a  parasite,  the  calculus  itself  may 
consist  of  concentric  layers  of  various  substances,  so  that  urates  and 
phosphates,  phosphates  and  lime  salts,  alternate  with  one  another. 

The  chemical  examination  of  the  stone  may  be  undertaken  in 
accordance  with  the  following  scheme.  Fragments  of  the  calculus 
are  heated  in  a  platinum  spoon  over  a  Bunsen  burner. 


Combustible. 


Without  flame 
and  smoke. 


With    flame 
and  smoke. 


Urates. 


Yellow  flame, 
uriniferous  odor. 

Pale  blue  flame 

(sulphur) 

Odor  of  asafcetida. 


Uric  acid, , 
Urate  of  sodium, 
potassium     and 
ammonium. 


Incrusted    albu- 
minoid  body. 


Cystin. 


VESICAL    CALCULUS. 


2  53 


Pulverized     stone 
foams  with  HC1. 

Carbonate  of  lime. 

Non-combustible. 

Pulverized    stone 
does     not      foam 
with  HC1. 

The  red-hot  pow- 
dered stone  foams 
with  HC1. 

Oxalate  of  lime. 

The  red-hot  pow- 
dered stone  does 
not  foam  with 
HC1. 

Earthy  phosphates, 
(lime,  magnesia.) 

The  position  of  stones  in  the  bladder  is  usually  the  same.  They 
follow  the  law  of  gravity,  and  generally  lie  in  the  deepest  part  of  the 
bladder,  which  of  course  varies  with  the  position  of  the  individual. 

From  these  freely  movable  stones  we  must  differentiate  those 
which  are  fixed  in  a  given  part  of  the  bladder.  The  latter  occur  as 
the  result  of  incrustation  of  threads,  which  I  have  observed  especially 
on  the  upper  wall  of  the  bladder,  and  may  also  occur  from  the  incrus- 
tation of  tumors. 

Calculi  are  also  found  in  diverticula,  being  so  situated  that  they 
may  either  fall  out  and  then  slip  back  again  as  the  patient  changes 
his  position,  or  else  being  firmly  incarcerated,  having  gradually  become 
larger  and  larger  until  they  have  reached  a  size  greater  than  the  opening 
of  the  diverticulum.  Their  exit  is  then  impossible.  They  are  then 
truly  encapsulated  stones,  which  are  very  seldom  met  with.  More 
frequently  I  have  observed  those  which  lie  first  within  the  diver- 
ticulum and  then  without  it.  These  cases  explain  the  apparently 
unaccountable  disappearance  of  calculi  whose  presence  had  been 
previously  determined. 

Finally  there  remain  to  be  mentioned  the  so-called  pipe-stones 
which  we  referred  to  when  considering  urethral  calculi.  A  portion 
of  the  stone  lies  in  the  posterior  urethra,  another  part  in  the  bladder. 
In  such  cases  the  sphincter  is  usually  somewhat  separated,  forming 
a  sort  of  tunnel  between  the  walls  of  which  the  stone  is  held. 

What  now  are  the  effects  of  calculi  upon  the  bladder?  In  many 
cases  none  whatever.  The  bladder  often  tolerates  stones  so  well 
that  not  only  does  the  individual  fail  to  recognize  their  presence, 
but  the  anatomical  relations  of  the  bladder  remain  entirely  normal. 
This  may  continue  as  long  as  no  infection  takes  place.  As  the  moving 
of  the  stone  back  and  forth  produces  lesions,  very  slight  it  may  be, 
but  yet  nevertheless  disposed  to  favor  infection,  it  cannot  continue 


254  DISEASES    OF    THE    URINARY    BLADDER. 

very  long.     Hence  it  follows  that  cystitis  is  not  a  symptom  of  stone 
in  the  bladder,  but  a  complication,  a  result  thereof. 

The  condition  of  the  bladder  is  therefore  the  same  as  in  cystitis. 
Well-formed  trabecular  are  not  uncommon.  They  are  due  to  hyper- 
trophy resulting  from  increased  work.  As  a  bladder  containing  cal- 
culi contracts  very  often,  as  the  outflow  of  urine  is  frequently  im- 
peded, and  as  there  is  frequently  repeated  irritation  of  the  vesical 
mucosa,  muscular  hypertrophy  naturally  results,  and  produces  the 
so-called  trabecular  bladder,  or  vessie  a  colonnes.  Hyperemia  or 
haemorrhage  affecting  the  mucous  membrane  may  be  present  or  absent. 
A  very  rare  occurrence  is  ulceration  due  to  pressure  of  the  stone. 
When  of  long  duration  calculous  cystitis  may  ascend  the  same  as  any 
other  cystitis  and  cause  pyelonephritis. 

SYMPTOMS,    DIAGNOSIS,    COURSE,    AND    PROGNOSIS. 

Vesical  calculus  has  three  cardinal  symptoms:  pain,  disturbance 
of  micturition,  and  changes  in  the  urine. 

The  pain  is  only  exceptionally  spontaneous  and  lasting;  generally 
it  is  produced  by  some  definite  cause.  If  the  patient  moves  much, 
or  if  he  rides  much  over  a  rough  road,  or  in  a  rickety  conveyance,  he 
experiences  a  painful  sensation  in  the  region  of  the  bladder,  in  the 
perineum,  and  particularly  at  the  end  of  the  penis.  At  times  this  pain 
becomes  so  great  that  it  prevents  the  patient  making  any  considerable 
movement  or  effort.  As  soon  as  the  patient  lies  down,  and  especially 
during  the  night,  he  is  free  from  pain. 

This  pain,  which  is  due  to  the  stone  falling  back  and  forth  when  the 
body  is  in  motion,  is  different  than  that  produced  by  contraction  of 
the  bladder.  As  soon  as  the  bladder  is  emptied  there  comes  a  moment 
just  at  the  close  of  micturition  when  the  mucous  membrane  contracts 
upon  the  rough  surface  of  the  stone.  This  makes  a  lancinating  pain 
which  radiates  to  the  end  of  the  penis.  As  soon  as  urine  collects  again 
in  the  bladder  and  separates  its  walls  from  the  stone  the  pain  subsides. 
Contraction  of  the  bladder  due  entirely  to  the  irritation  produced 
by  movements  of  the  stone  may  occur  irrespective  of  micturition,  and 
give  rise  to  sharp  pain  much  like  that  of  vesical  spasm. 

As  the  bladder  is  particularly  sensitive  in  the  region  of  the  neck, 
those  cases  in  which  the  stone  is  relatively  small  and  the  bladder  not 
too  large,  so  that  the  calculus  is  forced  to  the  neck  when  contractions 
occur,   are  the  most  painful.     For  this  reason  children  and  young 


VESICAL    CALCULUS.  255 

people  suffer  more  than  old  persons  with  large  dilated  bladders,  in 
some  pockets  of  which  the  stone  is  more  or  less  firmly  fixed.  Under 
certain  conditions  pain  may  be  entirely  wanting.  I  have  often  let 
patients  having  stone  jump  from  a  high  chair  without  causing  them 
any  pain. 

The  disturbances  of  micturition  consist  in  frequent  passing  of 
water  and  in  occasional  sudden  interruption  of  the  stream.  Here 
again  it  is  the  movements  of  the  body  which  are  responsible  for  the 
frequent  urination.  Therefore  it  points  strongly  to  stone  if  the  patient 
states  that  he  experiences  urgency  of  urination  only  during  the  day, 
and  particularly  when  walking  and  driving,  and  that  he  is  little  troubled 
by  it  at  night.  Many  patients  sleep  all  night  without  emptying  their 
bladder.  It  should,  however,  be  mentioned  that  this  symptom  of 
frequent  micturition  may  fail  entirely.  Particularly  in  old  persons 
with  dilated  bladders,  which  often  hold  over  a  liter  fi  quart]  without 
inducing  urgency  of  urination,  have  I  found  this  symptom  absent. 

The  other  sign,  sudden  interruption  of  the  stream,  is  even  more 
irregular.  It  occurs,  as  would  naturally  be  expected,  when  a  small 
calculus  is  forced  to  the  neck  of  the  bladder  by  vesical  contractions 
and  is  made  to  occlude  the  urethral  opening  in  a  manner  similar  to 
that  in  which  a  glass  ball  might  close  the  neck  of  a  bottle.  If  the 
patient  assumes  another  position,  especially  one  approaching  the 
horizontal  posture,  the  stone  sinks  back  into  the  fundus  and  the  patient 
can  urinate  again. 

It  is  very  rare  for  complete  retention  of  urine  to  be  caused  solely 
by  stone.  When  a  prostatic  who  also  has  a  vesical  calculus  is  seized 
with  retention  the  latter  condition  is  to  be  attributed  to  the  enlarged 
prostate  and  not  to  the  calculus.  It  is  constantly  observed,  and  is  due 
to  reflex  spasm  of  the  external  sphincter  engendered  by  the  irritation 
present  in  the  bladder. 

As  a  third  symptom  changes  in  the  urine  have  been  mentioned. 
The  most  important  peculiarity  is  admixture  of  blood.  In  this  respect 
we  must  differentiate  between  the  macroscopic  and  microscopic  detec- 
tion of  haemorrhage.  Only  the  first  is  commonly  so  designated  and  rec- 
ognized as  such  by  the  laity.  In  general  it  may  be  stated  that  these 
haemorrhages  are  the  rule  in  vesical  calculus.  They  occur  occasionally, 
and  as  is  the  case  with  pain  and  increased  frequency  of  urination,  are 
called  forth  by  forced  movements,  walking,  riding,  etc.  It  is  seldom  that 
they  occur  spontaneously  without  one  of  these  causes  being  present. 


256  DISEASES    OF    THE    URINARY    BLADDER. 

They  are  characterized,  furthermore,  by  the  fact  that  they  are 
usually  not  profuse  and  soon  disappear  if  the  patient  keeps  quiet 
or  goes  to  bed.  Under  such  circumstances  the  blood  may  be  voided 
with  the  urine,  or  appear  at  the  end  of  micturition  with  the  last 
drops  of  urine,  assuming  the  form  of  terminal  haemorrhage.  The 
latter  occurrence  is  probably  caused  by  the  stone  being  forced  against 
the  sphincter  at  the  close  of  the  act  and  thus  producing  a  slight  lesion. 
This  form  of  terminal  haemorrhage,  is  not  due,  therefore,  to  movement 
and  straining.  Here  again  it  must  not  be  omitted  to  state  that  both 
forms  of  haemorrhage  may  be  absent.  I  have  seen  patients  who  have 
suffered  with  stones  for  years  without  having  any  haemorrhage  whatever. 

A  sign  which,  according  to  my  observation,  hardly  ever  fails,  and  upon 
which  sufficient  stress  has  heretofore  not  been  laid,  is  the  presence 
of  blood-cells  in  the  urine.  Their  presence  can  be  demonstrated 
only  by  the  microscope.  It  is  with  the  greatest  rarity  that  I  have 
failed  to  find  them.  Where  a  stone  is  present  in  the  bladder  there 
also  will  be  blood-cells  present^  even  though  they  are  nothing  more 
than  a  few  of  the  so-called  shadows,  or  red  corpuscles  from  which  the 
coloring  matter  has  been  extracted. 

As  to  the  other  changes  in  the  urine  which  take  place  in  vesical 
calculus,  it  may  be  said  that  they  consist  in  admixture  of  mucus  and 
pus,  conditions  which  are  not  characteristic  of  calculous  disease, 
but  which  are  due  to  the  accompanying  cystitis.  The  excretion  of 
a  certain  amount  of  salts  is  the  expression  of  the  general  diathesis,  and 
at  times  may  be  of  value  from  a  therapeutic  standpoint. 

From  this  consideration  of  the  symptoms  it  will  be  seen  that  a 
positive  diagnosis  of  vesical  calculus  cannot  be  made  from  them. 
If  they  are  present  singly  or  collectively  we  may  suspect  the  existence 
of  a  stone.  Certainty,  however,  is  to  be  obtained  solely  by  physical 
examination  consisting  of  palpation,  the  introduction  of  a  stone- 
sound,  and  illumination  of  the  bladder. 

Palpation  and  sounding  have  been  relegated  to  an  unimportant 
place  by  cystoscopy,  but  notwithstanding  this  they  should  not  be 
abandoned,  for  there  are  cases  in  which  the  practice  of  cystoscopy  is 
technically  impossible.  An  attempt  should  always  be  made  to  palpate 
the  bladder,  first  through  the  rectum  and  then,  in  the  female  through 
the  vagina,  and  also  bimanually.  With  children  this  often  suffices, 
which  is  the  more  important  because  cystoscopy  is  difficult  in  them 
and  requires  the  use  of  specially  constructed  instruments. 


VESICAL    CALCULUS.  257 

If  an  instrument  can  be  introduced  into  the  bladder  the  use  of  the 
stone-sound  is  proper.  The  patient  lies  on  his  back  with  his  buttocks 
elevated  and  the  bladder  empty  or  only  slightly  filled.  When  the 
tip  of  the  sound  reaches  the  bladder  it  is  carried  by  a  slight  backward 
and  forward  movement  to  the  posterior  wall  drawn  back  toward  the 
right,  then  carried  to  the  left,  and  finally  with  its  beak  directed  down- 
wards brought  to  the  neck  of  the  bladder  again. 

If  a  stone  is  present  it  will  be  recognized  either  by  its  striking  per- 
ceptibly upon  the  metal  sound  or  by  the  tip  of  the  instrument  touching 
a  hard  object.  It  must  be  realized,  however,  that  this  examination 
is  not  reliable  in  all  cases.  It  is  to  be  borne  in  mind,  too,  that  the  sound 
striking  a  firm  trabecula  (muscle)  of  the  bladder  may  impart  a  sensa- 
tion, especially  to  those  of  little  experience,  of  striking  a  stone.  It  is 
more  important  to  realize  that  if  the  examination  is  negative  the  absence 
of  a  stone  is  not  proved.  The  stone  may  lie  in  a  diverticulum  or  in  a 
dilatation  behind  the  prostate;  it  may  be  hidden  by  contractions  of 
the  bladder  induced  by  the  sound  itself;  and  it  may,  especially  in 
women,  who  have  a  very  much  dilated,  distorted  and  irregular  blad- 
der, easily  escape  the  sound. 

Our  object  is  obtained  much  more  surely  and  quickly  with  the 
cystoscope.  In  the  great  majority  of  cases  a  glance  is  sufficient.  It 
not  only  shows  us  that  stone  is  present,  but  it  informs  us  also  whether 
there  are  several,  how  large  they  are,  what  color  they  have,  and  con- 
veys probable  though  not  absolute  knowledge  as  to  their  nature.  A 
stone  which  is  yellow  externally,  and  therefore  probably  composed 
of  urates,  may  have  an  oxalate  nucleus;  a  white  phosphatic  covering 
may  conceal  a  mass  of  urates,  and  so  on.  Furthermore  we  get  infor- 
mation in  regard  to  the  position  of  the  stone,  whether  it  is  free  or  mov- 
able, whether  it  lies  in  a  diverticulum.  Naturally  cystoscopy  may 
also  fail.  The  bladder  may  be  so  foul  that  it  is  utterly  impossible 
to  see  anything,  although  such  a  condition,  it  is  true,  is  exceedingly  rare. 
With  but  one  exception  I  have  always  succeeded  in  discovering  the 
stone.  It  has  happened  more  frequently  that  an  encapsulated  stone 
escaped  the  eye. 

In  such  difficult  cases  the  most  modern  method  of  examination, 
to  wit,  radioscopy,  may  be  resorted  to.  Unfortunately,  however, 
it  must  be  stated  that  this  method  does  not  furnish  reliable  results. 
Conditions  must  be  very  favorable  in  order  for  a  trustworthy  picture 
of  the  calculus  to  be  obtained.  The  most  common  primary  calculi, 
17 


'58 


DISEASES    OF    THE    URINARY    BLADDER. 


those  composed  of  urates,  allow  the  rays  to  pass  through  so  well  that 
their  contour  is  seldom  plainly  given. 

The  method  is  usually  satisfactory  in  children,  in  whom  it  is  particu- 
larly desirable,  for  the  reason  that  the  introduction  of  the  cystoscope 
is  beset  with  technical  difficulties;  for  very  small  children  it  is  imprac- 
ticable. Figure  164  shows  an  X-ray  picture  of  a  vesical  calculus  in  a  child 
seven  years  old. 

For  these  reasons  we  should  not  confine  ourselves  to  a  single  method 
of  examination,  but  should  use  all  if  it  be  necessary.     It  may  well 


Fig.  164. — X-ray  picture  of  a  vesical  calculus  in  a  child  seven  years  old. 

be  said  that  there  are  few  diseases  which  require  such  certainty  and 
precision  in  diagnosis  as  stone  in  the  bladder. 

The  course,  duration  and  termination  of  the  disease  are  most 
variable.  A  stone  may  be  present  for  years  or  tens  of  years  without 
causing  any  material  disturbance.  Therefore  many  old  persons 
prefer  not  to  be  operated  on,  and  carry  the  calculus,  which  burdens 
them  little  or  not  at  all,  as  long  as  they  live. 

Others  have  severe  pain,  urgency  of  micturition,  and  cystitis,  so  that 
interference  is  demanded.  As  a  rule  the  annoyance  depends  more 
upon  the  accompanying  symptoms,  particularly  cystitis,  than  upon 
the  stone  itself.  The  cystitis  is  characterized  by  haemorrhage  and  pain, 
which  appears  especially  in  the  form  of  exacerbations  or  attacks  of 


VESICAL    CALCULUS.  259 

vesical  spasm.  Very  rarely  the  stone  gets  wedged  into  the  neck  of 
the  bladder;  it  then  causes  most  violent  pain,  the  patient  urinating 
drop  by  drop  and  experiencing  great  distress.  Under  these  circum- 
stances haemorrhage  is  hardly  ever  absent. 

The  general  health  remains  good  for  a  long  time,  especially  while 
the  bladder  remains  uninfected.  If  cystitis  or  an  ascending  pyelo- 
nephritis develops,  then,  of  course,  the  symptoms  of  these  maladies 
manifest  themselves.  Irrespective  of  these  complications  there  occasion- 
ally occurs  a  condition  which  may  be  designated  as  urinary  intoxi- 
cation, a  condition  which  is  characterized  by  loss  of  appetite,  want 
of  strength,  thirst,  and  slight  elevation  of  temperature.  This  may  be 
attributed  to  absorption  of  toxins  of  the  urine  through  the  lesions 
in  the  bladder  produced  by  the  calculus. 

As  to  the  cystitis,  it  must  be  ascertained  whether  it  is  primary  or 
secondary,  that  is,  whether  it  developed  as  a  result  of  the  calculus, 
or  whether  it  is  responsible  for  the  formation  of  the  latter.  The  first 
form  is  easy  to  cure,  the 'second  difficult. 

The  prognosis  of  stone  in  the  bladder  is  usually  favorable.  Spon- 
taneous expulsion  is  not  to  be  counted  upon  except  in  the  case  of  very 
small  calculi.  It  occurs  most  frequently  in  women,  who  have  a  short 
and  wide  urethra. 

Spontaneous  fragmentation  of  the  stone  is  even  less  common, 
although  a  few  examples  are  on  record.  In  such  cases  it  is  probable 
that  the  inner  layers  of  the  calculus,  being  no  longer  in  contact  with 
the  urine,  become  dry, so  that  cleavage  takes  place,  and  that  the  latter 
occurrence,  in  conjunction  with  contraction  of  the  bladder,  leads  to 
spontaneous  crumbling  of  the  stone.  It  hardly  need  be  said  that 
primary  calculus  unassociated  with  complications  offers  a  better  prog- 
nosis than  do  the  secondary  forms  which  were  preceded  by  cystitis. 
The  most  unfavorable  cases  of  all  are  those  complicated  by  pyelo- 
nephritis. 

TREATMENT. 

The  object  of  treatment  in  vesical  calculus  is  twofold,  namely, 
to  remove  the  stone  which  is  present,  and  to  prevent  the  formation  of 
others.     The  first  can  be  attained  only  by  operation. 

There  was  a  time  when  it  was  considered  possible  to  dissolve  the  stone 
by  the  internal  administration  of  drugs,  but  we  no  longer  believe  in 
such  a  wonder.     A  series  of  operations  for  the  removal  of  stone  have 


260 


DISEASES    OF    THE    URINARY    BLADDER. 


been  recommended  and  practised.  We  cannot  enter  into  an  his- 
torical account  of  these  operations,  but  will  merely  engage  in  a  discus- 
sion of  those  which  in  the  present  state  of  our  knowledge  seem  to  be 


fn 


C 


the  most  rational.    As  a  rule,  the  choice  lies  between  cutting  operations 
and  crushing. 

Crushing  (lithotripsy,  litholapaxy). — In  the  writings  of  Hippoc- 


VESICAL    CALCULUS.  261 

rates,  Ambrose  Pare,  and  others  the  idea  of  crushing  stone  within 
the  bladder  was  mentioned,  but  Civiale,  who  in  1824  first  successfully 
put  it  into  practice,  was  the  founder  of  the  operation.  Although 
Heurteloup  and  Charriere  improved  the  instruments,  modern  litho- 
tripsy began  with  Bigelow.  In  1875  ne  invented  his  aspirator,  which 
made  it  possible  to  crush  the  stone  and  remove  the  fragments  at  one 
sitting.  He  named  this  operation  litholapaxy.  Next  to  him  the 
greatest  master  of  this  procedure  was  Sir  Henry  Thompson,  of  London. 
In  France  Felix  Guyon  became  the  best  advocate  of  the  method,  and 
has  brought  it  to  a  high  degree  of  perfection. 

For  the  performance  of  litholapaxy  lithotrites,  an  evacuator,  and 
catheters  of  large  caliber  are  required.  The  lithotrite  consists  of  male 
and  female  blades,  shaft  and  handle.  The  handle  is  provided  with  a 
mechanism  which  locks  and  unlocks  the  jaws  of  the  blades.  I  prefer 
the  instruments  of  Thompson  and  Guyon  (Figs.  165,  166  and  167). 


Fig.  168. — Forbes's  lithotrite. 

It  is  indispensable  that  the  instruments  be  made  of  the  best  and 
hardest  steel,  and  that  their  strength  be  tested.  The  jaw  of  the  female 
blade  (a)  of  Guyon's  instrument  is  indentated  so  that  the  teeth  of  the 
male  blade  (b)  fit  into  it.  This  mechanism  is  of  the  utmost  impor- 
tance, as  by  it  the  fragments  of  stone  can  be  forced  through  the  aper- 
tures. If  any  considerable  number  of  the  fragments  remained  in  the 
jaws,  the  lithotrite  could  not  be  entirely  closed,  and  its  removal  would 
be  very  difficult.  The  more  slender  instrument  (Fig.  167)  is  used 
at  the  end  of  the  operation  to  remove  the  last  small  fragments  of  stone. 
Because  of  the  shortness  of  its  beak  it  can  be  turned  in  all  directions 
and  even  carried  downward  in  the  bladder.  [The  late  Dr.  Wm.  S. 
Forbes,  of  Philadelphia,  constructed  a  lithotrite  (Fig.  168)  of  prodigious 
strength  which  seems  to  conform  better  to  the  laws  of  mechanics  than 
any  instrument  previously  devised.  It  also  contains  a  power- recording 
mechanism    in    the  screw  handle  which  measures  the  strain  on  the 


262 


DISEASES    OF    THE    URINARY    BLADDER. 


lithotrite  and  the  crushing  resistance  of  the  calculus.  A  complete 
description  of  this  lithotrite  is  contained  in  the  Transactions  0}  the 
American  Surgical  Association,  1894,  to  which  the  reader  is  referred.] 
Fig.  169  shows  Bigelow's  latest  evacuator.  It  consists  of  a  large 
rubber  bulb  and  a  glass  receiver.  The  stop-cock  in  the  bulb  permits 
the  bulb  to  be  filled  with  fluid  and  the  one  below  gives  attachment  to 
the  evacuating  tube.  Pressure  upon  the  bulb  forces  the  fluid  into  the 
bladder.  When  the  pressure  is  relaxed  the  bulb  reassumes  its  normal 
shape,  a  vacuum  is  created  within  it,  and  the  water  rushes  back  out 


Fig.  169. — Bigelow's  latest  evacuator. 


of  the  bladder  into  the  receiver  bringing  the  debris  of  the  calculus 
with  it. 

The  whole  instrument  except  the  rubber  bulb  can  be  boiled; 
the  bulb  is  sterilized  by  filling  it  with  1%  solution  of  bichloride  or 
oxycyanate  of  mercury  twenty-four  hours  before  it  is  to  be 
used.  If  the  patient  has  cystitis  his  bladder  should  be  cleansed 
by  a  preliminary  irrigation  of  silver  nitrate  solution  1 :  1000.  For 
crushing  large  stones  I  always  use  a  general  anaesthetic.  It  is  only  when 
the  calculi  are  small  and  their  crushing  requires  but  a  short  time 
that  it  can  be  dispensed  with. 

I  could  never  resolve  to  cocainize  the  bladder,  as  several  fatalities 


VESICAL    CALCULUS.  263 

resulting  from  this  procedure  have  been  reported.  We  do  not  know 
to  what  extent  the  bladder  absorbs  nor  how  much  cocain  the  patient 
will  tolerate.  On  the  other  hand,  insensibility  of  the  bladder  during 
operation  is  indispensable,  for  unless  it  be  obtained  the  bladder  will 
contract  so  that  some  part  of  its  lining  will  be  drawn  over  the  stone. 
In  such  a  case  it  will  be  very  difficult  to  avoid  injuring  the  bladder- wall. 

The  patient  is  placed  on  the  table  with  the  buttocks  elevated  and 
the  head  lowered,  as  in  this  position  the  stone  is  removed  from  the 
neck  of  the  bladder  and  the  operation  thus  made  more  easy.  If  the 
lithotrite  be  now  introduced,  it  will  often  be  merely  necessary,  while 
the  beak  of  the  instrument  is  directed  upwards,  to  open  and  close  the 
blades,  whereupon  the  stone  will  be  found  in  their  grasp.  Crushing 
can  then  be  easily  done,  unless,  as  very  rarely  happens,  the  stone  is 
of  such  exceptional  hardness  that  a  hammer  has  to  be  used  to  break 
it.  There  are  cases  in  which  the  stone  even  resists  the  latter  manipu- 
lation.    In  such  instances  litholapaxy  is  not  practicable. 

After  the  stone  has  been  seized  and  crushed  search  for  the  frag- 
ments is  made  in  the  same  region.  They  are  usually  easily  found, 
and  are  to  be  crushed  again  in  the  same  manner  as  the  original  calculus. 
Occasionally  the  beak  of  the  lithotrite  must  be  turned  to  the  right 
and  left.  The  crushing  is  continued  as  long  as  large  pieces  can  be 
grasped  between  the  blades. 

When  no  more  can  be  found  the  evacuating  catheter  is  introduced, 
the  pump  attached,  and  evacuation  begun.  This  procedure  removes 
all  fragments  small  enough  to  pass  through  the  catheter.  To  com- 
plete the  operation  the  small  short-beaked  lithotrite  (ramasseur), 
the  blades  of  which  can  easily  be  carried  to  the  inferior  wall  of  the 
bladder,  is  introduced.  With  this  instrument  smaller  pieces  can  be 
caught  and  broken  up. 

When  it  has  been  determined  that  no  more  fragments  are  present 
in  the  bladder,  a  i :  iooo  solution  of  silver  nitrate  should  again  be 
injected,  a  retention-catheter  inserted,  if  necessary,  and  the  patient 
put  to  bed.  If  severe  haemorrhage  has  occurred,  or  if  the  patient  can- 
not empty  his  bladder,  the  catheter  should  be  used.  Otherwise  it  is 
not  necessary. 

At  the  conclusion  of  the  operation  many  surgeons  like  to  assure 
themselves  by  a  look  through  the  cystoscope  whether  all  fragments 
have  been  removed,  but  I  consider  such  an  examination  useless.  Even 
if  only  slight  haemorrhage  has  occurred  the  bladder  is  so  obscured 


264  DISEASES    OF    THE    URINARY    BLADDER. 

that  a  clear  view  of  it  cannot  be  obtained.     It  is  better  to  undertake 
this  verification  a  few  days  later. 

The  dangers  of  this  operation  are  slight  provided  that  it  is  skill- 
fully performed.  It  often  happens  that  a  piece  of  mucous  membrane 
is  caught  with  the  stone  and  crushed,  but  this  is  without  untoward 
effect.  Perforation  of  the  ispp^jq  is  among  the  rarest  accidents. 
It  is  also  rare  for  the  lithotrite  to  bend  or  break,  yet  I  have  seen  such 
an  accident  happen. 

The  danger  is  materially  lessened  if  strict  asepticism  is  practised. 
Slight  irritation  of  the  bladder  is  often  produced,  but  it  soon  subsides. 
I  have  hardly  ever  seen  a  permanent  orchitis,  epididymitis,  or  pro- 
statitis as  a  sequel  of  the  operation. 

Litholapaxy  is  more  difficult  in  woman  than  in  man.  The  difficulty 
is  due  to  the  greater  distensibility  of  the  female  bladder,  to  the  distor- 
tion produced  by  its  numerous  pockets  and  folds,  and  to  the  absence 
of  a  firm  point  of  support  at  the  base  of  the  bladder  such  as  is  supplied 
in  the  male  by  the  prostate. 

Cutting  Operations. — The  only  cutting  operations  to  be  considered 
at  the  present  time  are  suprapubic  and  perineal  lithotomy.  The 
median  perineal  operation,  too,  is  ceding  more  and  more  to  the 
suprapubic.  In  performing  the  former  operation  the  regular  perineal 
incision  is  made,  but  is  prolonged  into  the  prostatic  urethra  in  order 
to  secure  more  room  for  the  removal  of  the  stone.  Even  then  great 
difficulty  may  be  experienced  in  its  extraction. 

Perineal  litholapaxy  is  a  slovenly  and  uncertain  procedure;  it  is 
impossible  to  tell  whether  all  of  the  stone  is  removed.  When  a  cutting 
operation  is  deemed  advisable,  it  is  best  to  resort  to  suprapubic  lithot- 
omy, which  permits  an  adequate  survey  of  existing  conditions  to  be 
made. 

The  suprapubic  incision  is  made  in  accordance  with  the  usual 
rules.  The  bladder  is  filled  with  air  and  an  incision  begun  a  hand's 
breath  below  the  umbilicus  and  carried  down  toward  the  symphysis. 
The  patient  lies  in  the  Trendelenburg  position.  The  transverse 
incision  above  the  symphysis,  although  it  gives  more  room,  is  not 
necessary  for  the  performance  of  this  operation.  The  bladder  is 
opened  without  injuring  the  peritoneum,  and  the  wound  enlarged 
until  the  stone  can  be  removed  with  one  of  the  forceps  shown  in  Fig. 
170;  the  stone  scoop  is  also  useful  for  this  purpose. 

It  is  better  to  make  the  incision  too  large  than  too  small,  so  that 


VESICAL    CALCULUS. 


265 


in  delivering  the  stone  the  edges  of  the  vesical  wound  shall  not  be 
bruised.  After  the  calculus  is  removed  the  bladder  is  washed  with 
silver  nitrate  solution  and  either  closed  entirely  or  a  small  opening 
left.  If  haemorrhage  is  not  severe  and  the  bladder  was  not  too  foul, 
it  is  better  to  close  the  bladder  entirely  and  insert  a  retention-catheter 
through  the  urethra.  When  ammoniacal  decomposition  of  urine 
exists  a  small  slit  is  left  open  in  the  bladder  and  a  drainage-tube  inserted. 


Fig.  170. — Stone-forceps  and  scoop. 


After  packing  the  prevesical  space  the  superficial  wound  is  closed  with 
the  exception  of  a  small  slit  at  its  lower  angle. 

This  operation  is  simple  and  offers  a  good  prognosis  except  in  the 
case  of  very  decrepit  persons  or  those  suffering  from  advanced  arterio- 
sclerosis or  kidney  disease. 

It  has  been  asserted  that  more  relapses  take  place  after  litholapaxy 
than   after  suprapubic  lithotomy,   because  in  the  first  procedure  it 


266  DISEASES    OF    THE    URINARY    ELADDER. 

cannot  positively  be  known  whether  every  fragment  of  stone  is  removed. 
If  a  piece  remains  it  soon  grows  to  form  a  new  stone.  Experience 
teaches  that  in  the  hands  of  those  operators  who  thoroughly  under- 
stand how  to  perform  the  operation,  litholapaxy  is  not  followed  by 
more  relapses  than  is  suprapubic  lithotomy.  Cystoscopy  in  con- 
junction with  litholapaxy  enables  one  to  free  the  bladder  from  all 
remnants  of  stone.  Moreover,  according  to  my  experience,  the 
effects  of  a  skillfully  performed  crushing  operation  are  not  so  severe 
as  those  caused  by  suprapubic  section.  Even  granting  that  there 
be  danger  of  a  repetition  of  the  operation,  I  consider  crushing  under 
otherwise  favorable  conditions  to  be  the  less  dangerous  procedure. 
The  cutting  operation  should  be  reserved  for  those  cases  in  which 
crushing  is  impossible. 

TUMORS  OF  THE  BLADDER. 

The  newer  methods  of  examination,  especially  cystoscopy,  have 
taught  us  that  new  growths  of  the  bladder  are  much  more  common 
than  was  formerly  supposed.  A  classification  of  these  growths  which 
would  be  satisfactory  in  all  respects  would  be  difficult  to  make.  They 
have  been  divided  according  to  the  anatomical  substratum  upon 
which  they  rest,  into  epithelial,  connective  tissue,  and  muscular  tumors. 
They  have  also  been  classified  according  as  they  are  superficial  and 
pedunculated  or  sessile,  or  according  as  they  are  deeply  situated 
and  infiltrate  the  wall  of  the  bladder.  The  most  natural  method  of 
classifying  is  to  divide  them  into  benign  and  malignant,  but  this  divi- 
sion also  is  subject  to  great  difficulties,  as  we  shall  presently  see. 

The  most  common  benign  tumor  is  papilloma,  which  may  be 
sessile  or  pedunculated,  single  or  multiple.  The  most  common  form 
in  which  this  growth  is  met  with  is  as  a  number  of  tumors  growing 
from  a  common  pedicle  like  the  branches  of  a  tree  from  its  trunk. 
The  branches  are  villi,  each  one  of  which  is  composed  of  a  fine  stroma 
of  connective  tissue  having  a  loop  of  blood-vessels  extending  to  its 
extremity,  and  being  covered  with  several  layers  of  epithelium  (Fig.  171). 
When  dry  these  villi  collapse,  but  when  brought  in  contact  with  fluid 
they  unfold  and  float,  as  they  are  seen  to  do  when  viewed  through  the 
cystoscope. 

When  the  connective  tissue  stroma  is  strongly  developed  the  tumor 
is  called  a  fibrous  papilloma ;  when  the  villi  are  arranged  in  series 
of    thread-like   forms   it   is   known,  according    to    Thompson,  as    a 


TUMORS  OF  THE  BLADDER. 


267 


fimbriated  papilloma  (Fig.  172).  These  different  names  should  be 
known,  because  if  they  are  not,  confusion  will  be  caused  when  the 
different  varieties  are  designated.  It  must,  moreover,  be  remembered 
that  Virchow  calls  these  same  neoplasms  papillary  fibromata,  that 
Kuster  designates  them  as  villous  polypi,  and  that  others  merely 
term  them  papillomata. 


Mlik 


Fig.  171. — Villous  papilloma. 


Although  these  villous  polypi  are  generally  benign,  it  must  not  be 
forgotten  that  such  is  not  always  the  case,  inasmuch  as  they  may 
extend  over  a  wide  area,  or  be  benign  as  to  their  superficial  portion 
only,  the  deep  parts  and  base  becoming  malignant;  furthermore 
cancerous  growths  may  present  villosites  on  their  surface.  Thus  it  is 
seen  that  it  may  be  very  difficult  to  decide  whether  a  tumor  is  benign 


208  DISEASES    OF    THE    URINARY    BLADDER. 

or  malignant.     In  practice,  however,  it  will  generally  be  correct  to 
call  a  villous  or  papillomatous  tumor  benign. 

Much  rarer  are  true  fibromata,  which  generally  occur  in  the  form 
of  pedunculated  polypi,  and  which  lead  to  those  rarer  growths,  fibro- 
myxoma,  myoma,  and  adenoma.  Sarcoma,  enchondroma,  angioma, 
chondro- sarcoma,  and  dermoids  have  also  to  be  mentioned;  of  these, 
however,  I  have  seen  none  but  sarcoma,  a  growth  which  is  not  very 
rare,  and  which  of  course  is  malignant.  [J.  A.  Wilder,  of  Denver, 
has  recently  analyzed  fifty  cases  of  sarcoma.  Twenty-six  of  this 
number  occurred  after  forty  years  of  age  and  fourteen  before  the  age 


Fig.  172  — Fimbriated  papilloma. 


of  ten.  Thus  it  is  seen  that  the  disease  is  most  common  in  middle 
life  and  in  childhood;  it  may,  however,  occur  at  any  age. 

Wilder  states  that  it  is  rapidly  fatal  in  children,  and  that  metastases 
as  compared  with  sarcoma  in  other  parts  of  the  body  seem  rare.] 
[Chorio-epithelioma.  Dewitski  has  recently  reported  a  case  of 
chorio- epithelioma  occurring  in  a  virgin  aged  seventy- five  years,  and 
terminating  fatally. 

Microscopic  examination  of  the  vesical  tumor  revealed  Langhans 
cells  and  syncytium. 

The  genital  organs  were  free  from  similar  tissue,  although  fibro- 
myomatous  nodules  were  found  in  the  uterus.  Metastases  were  present 
in  the  lungs,  spleen  and  intestines. 


TUMORS    OF    THE    BLADDER.  269 

This  is  the  only  case  of  the  kind  yet  reported,  although  Lubarsch 
mentions  one  somewhat  similar,  which  occurred  in  a  girl  aged  thirteen. 
In  his  case,  however,  the  growth  probably  originated  in  the  uterus. 
This  patient  was  also  a  virgin. 

For  further  particulars  the  reader  is  referred  to  Dewitski's  paper 
in  the  Medicinische  Woche,  August  7  and   14,   1905.] 

Of  the  greatest  importance,  however,  is  cancer,  which  occurs  very 
frequently.  It  appears  in  different  forms,  varying  from  a  prodigious 
tumor  growing  into  the  cavity  of  the  bladder  to  a  layer  of  tissue 
merely  infiltrating  the  vesical  walls.  In  the  first  instance  the  growth 
may  be  either  pedunculated  or  sessile;  the  surface  may  be  smooth  or 
irregular,  or  it  may  be  villous,  and  thus  be  mistaken  for  a  benign  papil- 
loma. The  villi  are  exactly  the  same  as  those  of  papillomata,  the  only 
difference  being  in  the  base  of  the  tumor.  While  in  the  benign  growth 
the  connective  tissue  stroma  arises  directly  from  the  submucosa, 
in  villous  carcinoma  there  is  a  small-celled  infiltration  in  the  base  of 
the  tumor,  together  with  an  irregular  proliferation  of  epithelium 
extending  into  the  deeper  parts. 

The  superficial  carcinomata,  to  which  class  the  scirrhus,  alveolar 
and  melanotic  forms  belong,  cause  diffuse  or  superficial  induration 
of  the  bladder,  which  can  usually  be  detected  by  palpation  through 
the  rectum. 

Carcinomata,  like  benign  growths,  may  be  multiple,  and,  indeed, 
pedunculated  malignant  villous  cancer  and  infiltrating  cancer  may 
be  found  together.  It  has  also  been  observed  that  pedunculated 
cancer  may  recur  after  operation  as  an  infiltrating  growth. 

It  is  highly  interesting,  too,  to  note  that  apparently  authentic  cases 
of  the  transformation  of  a  benign  into  a  malignant  growth  have  been 
reported.  In  such  cases  it  is,  of  course,  necessary  to  be  certain  that 
no  error  as  to  the  nature  of  the  original  growth  occurred. 

The  extension  of  the  cancerous  masses,  especially  those  forms  which 
grow  into  the  cavity  of  the  bladder,  may  assume  enormous  dimensions, 
so  that  the  viscus  may  be  almost  entirely  filled  by  them. 

The  difficulty  of  determining  from  the  macroscopic  inspection  or 
the  cystoscopic  appearance  of  a  growth  whether  it  is  benign  or  malig- 
nant is  shown  by  the  fact  that  great  differences  as  to  their  relative 
frequency  are  found  in  the  literature  of  the  subject.  According  to 
my  experience,  which  embraces  more  than  sixty  cases,  cancer  is  more 
common  than  benign  tumors.     The  great  majority  of  cancer  cases 


270  DISEASES    OF    THE    URINARY    BLADDER. 

occur  in  elderly  people,  affecting  mostly  those  who  are  over  fifty  years 
of  age;  the  benign  tumors  more  commonly  affect  younger  persons. 

We  know  very  little  concerning  the  causes  of  tumors  of  the  bladder. 
Prolonged  irritation  of  the  vesical  mucous  membrane  has  been  assigned 
as  a  cause,  but  there  are  countless  cases  of  chronic  catarrh  of  the 
bladder  in  which  catheterism  and  its  resulting  irritation  are  not  followed 
by  neoplastic  growths.  There  are  innumerable  cases  of  calculus  unasso- 
ciated  with  the  development  of  tumors,  and,  conversely,  new  growths 
are  found  in  cases  in  which  no  irritation  of  the  wall  of  the  bladder  has 
taken  place.  It  is  true  that  catarrh  of  the  bladder  may  lead  to  pro- 
liferation of  the  vesical  mucous  membrane,  so  that  tumor-like  out- 
growths resembling  villi  may  be  formed,  but  these  are  different  from 
true  papillomata. 

It  would  seem  that  chemical  irritation  by  certain  dye-stuffs  is  espe- 
cially prone  to  result  in  the  development  of  vesical  tumors.  Many 
cases  have  been  observed  in  persons  who  work  in  fuchsin,  so  that  it 
seems  justifiable  to  assume  that  the  anilin  and  toluidin  which  they 
handle  exerts  an  irritating  influence  upon  the  walls  of  the  bladder. 

It  has  been  asserted  that  gonorrhoea  and  syphilis  of  the  bladder 
give  rise  to  tumors,  but  as  no  proof  has  been  adduced  to  show  the 
truth  of  this  assertion  the  existence  of  a  causative  relation  between 
these  diseases  and  tumors  can  be  totally  denied. 

It  also  seems  to  me  to  be  very  doubtful  whether  tumors  can  be  pro- 
duced by  the  action  of  parasites.  At  all  events  it  may  be  stated 
that  there  is  no  proof  of  such  an  occurrence.  It  is  seen,  then,  that  we 
are  ignorant  in  respect  to  the  causes  producing  tumors  of  the  bladder, 
knowing  no  more  about  their  origin  than  we  know  of  the  origin  of 
new  growths  in  other  organs  of  the  body. 

As  to  the  relative  frequency  in  the  two  sexes  I  have  found  them  to 
occur  more  frequently  in  men  than  in  women.  In  this  respect,  how- 
ever, it  must  be  borne  in  mind  that  a  distinction  has  to  be  made  between 
primary  and  secondary  growths,  a  distinction  which,  of  course,  applies 
only  to  malignant  forms. 

The  secondary  tumors  are  due  either  to  metastasis  from  a  growth 
situated  in  another  portion  of  the  body  or  to  extension  by  contiguity 
from  neighboring  parts.  Many  a  vesical  carcinoma  is  merely  the 
extension  of  a  prostatic  carcinoma.  So  likewise  may  a  carcinoma 
of  the  uterus  or  its  adnexa  grow  into  the  bladder.  Contrary  to  the 
observations  of  Giiterbock  I  find  secondare  carcinoma  of  the  bladder 


TUMORS    OF    THE    BLADDER.  27 1 

to  be  more  frequent  in  men  than  in  women.     Metastases  from  other 
organs  are  generally  conceded  to  be  rare. 

The  site  of  tumors  is  by  preference  the  trigonum,  the  base  of  the 
bladder,  and  the  region  of  the  ureters.  This  is  especially  true  of 
malignant  growths.  I  have  often  found  papillomata  on  the  superior 
and  lateral  walls  of  the  bladder.  Nothing  definite  can  be  said  in 
regard  to  the  size  of  vesical  tumors ;  they  vary  from  the  size  of  a  pea 
to  that  of  a  hen's  egg.  Finally  it  is  worthy  of  mention  that  malignant 
tumors  remain  confined  to  the  bladder  for  a  long  time,  metastases 
occurring  comparatively  late. 

SYMPTOMS,   PROGNOSIS   AND   COURSE. 

In  the  beginning  of  the  disease  there  is  little  difference  between 
the  symptoms  produced  by  benign  and  malignant  tumors.  The 
following  symptoms  are  common  to  all  tumors  of  the  bladder:  haema- 
turia,  pain,  disturbances  of  micturition,  and  expulsion  of  fragments 
of  the  tumor.  All  these  symptoms,  however,  need  not  be  present  in 
a  single  case,  although  they  may  be.  In  some  cases  nothing  but  haema- 
turia  is  present,  in  other  pain  is  the  chief  symptom,  and  in  still  others 
the  only  thing  noticed  is  the  expulsion  of  particles  of  the  tumor. 

The  symptom  of  greatest  significance,  and  the  one  which  usually 
first  directs  our  attention  to  the  malady,  is  haematuria.  It  often  re- 
mains for  years  the  only  perceptible  sign  of  the  disease.  The  haemor- 
rhage has  distinct  characteristics,  being  generally  abundant,  of  long 
duration,  and  occurring  irrespective  of  injury,  violent  efforts,  or  strain- 
ing. It  is  very  obstinate  in  yielding  to  our  therapeutic  measures,  and 
finally  disappears  for  as  little  reason  as  it  apparently  took  place,  per- 
haps to  recur  after  a  long  lapse  of  time,  extending  frequently  over 
several  years.  It  may,  however,  recur  in  a  few  days  after  its  cessation. 
Very  often  the  haemorrhage  is  entirely  painless,  and  is  also  unaccom- 
panied by  tenesmus  unless  it  be  so  abundant  as  to  cause  the  forma- 
tion of  large  clots  in  the  bladder,  which  give  rise  to  vesical  contrac- 
tions. In  other  cases  the  bleeding  is  slight  and  partakes  of  the  nature 
of  terminal  haemorrhage,  only  a  few  drops  of  blood  being  forced  out 
at  the  end  of  micturition.  I  have  observed  this  occurrence  particu- 
larly when  the  tumor  was  close  to  the  neck  of  the  bladder,  so  that  a 
few  villi  were  compressed  by  the  sphincter  at  the  close  of  micturition. 

The  haemorrhage  is  not  well  explained  by  assuming  that  it  is  due  to 
ulceration  of  the  tumor,  for  when  ulceration  occurs  it  usually  produces 


272  DISEASES    OF    THE    URINARY    BLADDER. 

persistent  haemorrhage,  which  recurs  after  intervals  of  a  few  days, 
during  which  the  urine  is  voided  clear.  In  the  benign  papillary 
growths  it  is  chiefly  due  to  disintegration  of  the  epithelium  covering 
the  vascular  loop  of  the  villi;  the  vessel  then  lies  bare  and  powerful 
contraction  of  the  bladder  causes  it  to  rupture.  Very  often  circulatory 
disturbances  exist  in  the  region  around  the  tumor,  the  vessels  being 
congested  so  that  they  rupture  when  the  bladder  contracts. 

The  nature  of  the  tumors  cannot  be  determined  by  the  severity 
of  the  haemorrhage.  It  cannot  be  said  that  a  tumor  which  causes 
violent  bleeding  is  malignant,  or  that  one  which  produces  only  slight 
haemorrhage  is  benign.  I  have  seen  simple  polypi  bleed  profusely, 
and  have  known  carcinomata  to  cause  very  little  haemorrhage. 

Experience  has  taught  me,  however,  that  a  tumor  which  bleeds 
constantly,  haemorrhage  being  interrupted  merely  by  the  passage 
of  non-sanguinolent  urine  for  a  few  days  at  a  time,  is  nearly  always 
malignant.  Mention  has  already  been  made  of  the  fact  that  haemor- 
rhage may  remain  absent  a  long  time.  A  lady  under  my  care  had  no 
recurrence  for  seven  years. 

Pain  is  a  most  inconstant  symptom.  It  may  be  entirely  absent, 
and  in  benign  growths  usually  is  wanting  unless  the  tumor  is  situated 
near  the  neck  of  the  bladder.  In  event  of  the  latter  condition  the 
interference  with  micturition  is  associated  with  pain,  which  usually 
supervenes  as  the  last  drops  of  urine  are  voided.  Even  malignant 
tumors  may  exist  for  a  long  time  without  causing  any  pain;  some, 
however,  give  rise  to  pain  which  radiates  to  the  thighs,  or  to  the  anus 
and  perineum.  Such  pain  is  generally  attributed  to  pressure  of  the 
growth  or  its  metastases  upon  the  nerves  supplying  these  regions. 

Although  pain  in  the  bladder  is  a  symptom  in  a  great  many  cases 
of  vesical  tumor,  it  is  to  be  attributed  to  the  accompanying  cystitis; 
of  this  fact  I  have  often  had  opportunity  to  convince  myself. 
If  the  cystitis  be  treated  correctly  and  subdued  by  proper  internal 
and  local  remedies,  the  pain  diminishes  and  not  unfrequently  dis- 
appears. 

In  most  cases,  too,  the  disturbances  of  micturition  depend  upon  the 
associated  cystitis,  and  as  the  latter  condition  improves  they  disappear 
or  become  less  severe.  Those  cases  in  which  the  tumor  is  near  the 
neck  of  the  bladder,  so  that  it  constitutes  a  mechanical  impediment 
to  the  outflow  of  urine,  constitute  an  exception  to  this  rule. 

The  presence  of  fragments  of  tumor  in  the  urine  affords  a  valuable 


TUMORS    OF    THE    BLADDER.  273 

diagnostic  sign,  but,  unfortunately,  in  the  majority  of  cases  none  are 
voided.  Occasionally,  however,  pieces  are  passed  with  the  urine, 
and  at  times  some  are  brought  away  by  irrigation  of  the  bladder. 
This  happens  especially  in  papillomata,  their  peripheral  portion  being 
easily  broken  off.  The  method  formerly  in  vogue  of  endeavoring 
to  tear  off  a  small  piece  of  a  suspected  growth  with  a  catheter  is  no 
longer  employed,  because  there  are  at  present  better  and  less  dangerous 
methods  of  diagnosis. 

These  methods  comprise  palpation  and  cystoscopy.  Palpation, 
of  course,  gives  results  only  when  it  is  positive.  A  tumor  infiltrating 
the  wall  of  the  bladder  can  be  felt  through  the  rectum,  and  in  the 
female  through  the  vagina;  but  when  palpation  proves  negative  we 
cannot  assert  that  a  tumor  is  not  present,  for  there  may  be  one  so  small 
or  so  superficial  that  it  cannot  be  felt. 

Much  more  reliable  and  certain  are  the  results  of  cystoscopy. 
Usually  only  a  glance  is  required  to  show  that  a  neoplasm  is  present 
in  the  bladder.  (Compare  the  cystoscopic  pictures  pages  41  and  42.) 
A  skillful  examiner  can  without  difficulty  wash  the  bladder  so  clean  that 
he  can  obtain  a  perfect  view  of  the  bladder-walls  and  cavity.  It  is 
only  in  very  rare  cases  of  severe  haemorrhage  that  this  cannot  be  done. 
The  haemorrhage  may  be  so  severe  that  examination  even  with  the 
irrigating  cystoscope  will  not  afford  any  information.  In  such  cases 
nothing  can  be  done  except  to  wait  for  the  haemorrhage  to  stop,  or  at 
least  diminish,  and  again  undertake  to  illuminate  the  bladder.  The 
danger  of  a  patient  bleeding  to  death  because  of  this  delay  is  very 
slight;  I  have  seldom  seen  a  patient  bleed  to  death  from  a  tumor 
of  the  bladder. 

If  the  bladder  can  be  inspected  through  the  cystoscope,  then  cystos- 
copy will  give  information  as  to  the  size  of  the  tumor,  its  location, 
its  shape,  whether  it  is  pedunculated  or  sessile,  whether  it  presents 
villi,  whether  more  than  one  growth  is  present,  etc.  It  is  in  the  diagnosis 
of  vesical  tumors  that  cystoscopy  has  attained  its  greatest  triumph. 

Cystitis  is  a  very  common  complication  of  vesical  tumors.  It  may 
develop  spontaneously  or  arise  as  the  result  of  catheterization.  In 
malignant  growths  the  appearance  of  spontaneous  cystitis  is  not  long 
delayed,  whereas  benign  growths  may  exist  for  years  without  it  develop- 
ing. This  form  of  cystitis  is  dependent  upon  infection  the  same  as 
all  other  forms  are. 

It  may  be  that  blood-clots  which  remain  at  the  base  of  the  bladder 
iS 


2  74  DISEASES    OF    THE    URINARY    BLADDER. 

a  long  time  and  become  decomposed  are  the  causative  factors,  although 
the  congestion  always  present  in  association  with  a  neoplasm  of  the 
bladder  supplies  favorable  conditions  for  the  reception  of  infective 
microorganisms.  If  the  catheter  is  employed,  be  it  for  diagnostic 
or  for  therapeutic  purposes,  the  urine  frequently .  becomes  turbid 
despite  our  most  careful  antiseptic  and   aseptic  precautions. 

This  cystitis  differs  little  from  other  forms,  except  that  it  is  frequently 
associated  with  haemorrhage  and  is  very  difficult  to  control.  In  cases 
of  benign  tumor  the  urine  will  often  clear  up,  but  in  case  of  malignant 
growth  our  efforts  are  generally  in  vain.  The  symptoms  can  be 
ameliorated,  the  strangury  and  pain  lessened,  but  the  urine  can  seldom 
be  rendered  entirely  clear.  An  ulcerative  process  is  often  present, 
and  the  products  of  ulceration  keep  up  the  infection,  or  cause  it  to 
become  more  diffuse. 

If  the  tumor  is  so  situated  that  it  occludes  the  orifice  of  a  ureter, 
or  interferes  with  the  outflow  of  urine  from  the  same,  engorgement 
of  the  corresponding  kidney  results.  As  long  as  infection  does  not 
take  place  the  condition  is  merely  a  hydronephrosis,  but  whenever 
infection  occurs  it  becomes  converted  into  a  pyonephrosis  or  pyelo- 
nephritis. 

The  course  of  the  disease  depends  upon  the  occurrence  or  non- 
occurrence of  these  complications.  Benign  tumors  may  be  present 
in  the  bladder  for  years  or  decades  without  producing  any  disturbance 
whatever,  the  only  untoward  effect  being  an  occasional  attack  of 
urinary  haemorrhage.  The  patient  neither  presents  the  aspect  of 
illness  nor  complains  of  feeling  ill. 

If  the  tumor  grows  so  that  the  cavity  of  the  bladder  becomes  much 
diminished  in  size,  nature  endeavors  to  afford  relief  by  causing  a  spon- 
taneous breaking-off  and  expulsion  of  villi.  In  other  cases  the  tumor 
grows  so  large  as  to  cause  the  patient  discomfort.  The  bladder  comes 
to  have  less  and  less  room  for  the  reception  of  urine,  urgency  of  urina- 
tion becomes  frequent,  and  as  the  result  of  increased  vesical  contrac- 
tions the  haemorrhages  occur  more  often. 

The  course  of  malignant  tumors  is  different.  Haemorrhage  occurs 
more  frequently  than  in  benign  tumor.  The  amount  of  blood  lost 
is  less  than  in  the  latter  form  of  the  disease,  but  the  intervals  at  which 
bleeding  occurs  are  shorter.  The  persistent  loss  of  blood,  the  severe 
disturbances  dependent  upon  the  irrepressible  urgency  of  micturition 
which  deprives  his  nights  of  rest,  together  with  the  occurrence  of 


TUMORS    OF    THE    BLADDER.  275 

metastases,  combine  to  produce  a  general  enfeeblement  and  cachexia, 
which  usually  cause  the  patient  to  succumb,  unless  the  kidney  com- 
plications already  mentioned  develop  and  hasten  the  termination 
of  life. 

TREATMENT. 

Our  therapeutic  efforts  in  dealing  with  tumors  of  the  bladder  may 
consist  either  in  the  use  of  palliative  measures  intended  to  mitigate 
the  suffering  of  our  patients,  or  in  the  employment  of  radical  means 
for  the  removal  of  the  neoplasm. 

The  symptomatic  treatment  of  benign  and  malignant  tumors  is 
identical.  Strangury,  pain  and  haemorrhage  have  to  be  combated. 
For  this  purpose  narcotics  (heroin,  dionin,  morphine,  opium,  bella- 
donna) may  be  given  internally;  or  rectal  injections  of  antipyrin  i.o 
[15  grains]  and  laudanum  10  to  20  drops,  may  be  employed,  together 
with  irrigation  of  the  bladder. 

In  general  the  treatment  directed  to  subjugation  of  the  cystitic 
symptoms  is  the  same  as  that  advocated  in  the  article  on  the  treat- 
ment of  cystitis. 

Great  difficulty  is  sometimes  experienced  in  arresting  haemorrhage. 
Although  the  bleeding  seldom  causes  death,  severe  haemorrhage  of 
short  duration,  or  constant  slight  haemorrhage,  may  weaken  the  patient 
to  a  dangerous  degree.  We  must  therefore  always  endeavor  to  master 
such  haemorrhage.  Unfortunately,  styptics  administered  internally  al- 
most invariably  fail  to  do  good.  I  have  hardly  ever  seen  any  noticeable 
effect  exerted  by  the  astringents,  such  as  tannin,  acetate  of  lead,  and 
solution,  of  sesquichloride  of  iron;  ergotin  and  suprarenal  extract 
have  also  failed.  Subcutaneous  injections  of  gelatine  are  both  painful 
and  uncertain  in  their  action.  Therefore  when  the  haemorrhage  does 
not  abate  under  rest  and  quietude  recourse  should  be  had  to  local 
treatment.  A  fairly  reliable  remedy  is  a  strong  solution  of  silver 
nitrate.  After  emptying  the  bladder  100  cc.  [about  3  ounces]  of  a 
1:1000-1:500  solution  are  injected  into  the  bladder.  The  use  of 
larger  quantities  than  this  should  be  avoided,  as  it  is  not  desirable  to 
distend  the  bladder  and  separate  its  walls.  The  injections  may  be 
given  at  intervals  of  two  days.  Not  uncommonly  an  eschar  will  be 
formed  over  the  bleeding  area  and  the  desired  effect  thus  obtained. 
I  cannot  speak  so  favorably  of  methylene  blue  injections,  which  have 
been  highly  praised.     I  have   not  been  able  to  convince  myself  that 


276  DISEASES    OF    THE    URINARY    BLADDER. 

they  influence  bleeding  or  relieve  pain.  Further  experience  is  needed 
to  determine  the  value  of  suprarenal  extract  as  a  local  styptic.  My 
experience  with  it  up  to  the  present  time  has  been  unsatisfactory. 
I  have  seen  a  few  favorable  results  follow  the  injection  into  the  blad- 
der of  100  cc.  [about  3  ounces]  of  Merck's  2%  sterilized  solution  of 
gelatine. 

If  despite  the  employment  of  these  local  measures  the  bleeding  still 
persists,  then  the  introduction  of  a  permanent  catheter  is  indicated, 
in  order  that  the  vesical  contractions  may  be  stilled  and  the 
bladder  put  entirely  at  rest.  In  this  way  it  will  usually  be  possible 
to  check  the  haemorrhage  and  subdue  the  irritation;  indeed,  it  may  be 
stated  that  haemorrhage  from  a  benign  growth  may  always  be  controlled 
in  this  manner.  Patients  having  malignant  growths  may  thus  be  made 
to  lead  a  tolerable  existence.  Those  having  simple  papillomata  are 
almost  always  free  from  suffering.  It  often  happens  that  they  are 
reminded  of  their  disease  only  by  the  occurrence  of  a  haemorrhage. 

As  to  the  question  of  radical  treatment  directed  to  the  removal 
of  the  tumor,  a  distinction  must  be  made  according  as  the  growth  is 
benign  or  malignant. 

Benign  tumors — and  here  it  is  well  to  recall  the  restriction  we  made  in 
regard  to  the  possibility  of  determining  the  nature  of  a  growth  by  means 
of  cystoscopy  and  its  gross  appearance — should  be  removed,  provided 
that  there  is  no  contraindication  to  surgical  intervention.  There  are 
two  ways  by  which  this  can  be  accomplished,  namely,  the  intravesical 
method  by  means  of  the  operative  cystoscope,  and  a  suprapubic 
incision. 

The  intravesical  method  has  often  been  assailed.  It  is  considered 
dangerous  and  useless.  My  experience,  which  comprises  about 
thirty  cases,  is  as  follows.  In  the  first  place  removal  of  the  tumor 
with  the  cold  or  gal vano- caustic  snare  is  not  dangerous.  I  have  mot 
seen  a  single  accident  follow,  especially  any  dangerous  haemorrhages. 
It  is  really  astonishing  how  little  blood  is  lost.  The  tumor  must  be 
firmly  encircled  with  the  snare  and  then  torn  away  or  burned  off  with 
the  galvano-cautery. 

In  those  cases  in  which  the  pedicle  of  the  tumor  can  be  reached  the 
method  is  also  useful.     I  have  a  series  of  perfect  cures  to  record. 

It  must  be  limited,  however,  to  those  cases  in  which  the  tumor  is 
favorably  situated  for  its  employment.  If  it  be  used  for  cases  in  which 
only  the  peripheral  portion  of  the  growth  can  be  seized,  the  operation 


TUMORS    OF    THE    BLADDER.  277 

becomes  a  farce  which  might  better  be  left  unplayed.  Tumors  near 
the  neck  of  the  bladder  are  not  suitable  for  removal  by  this  method; 
those  at  the  base  and  on  the  posterior  wall  are  favorably  located. 

Furthermore  it  must  be  emphatically  stated  that  injury  may  be 
done  by  intravesical  manipulation  if  a  malignant  tumor  be  mistaken 
for  a  benign  one.  In  a  few  cases  where  this  mistake  was  made  I  have 
seen  severe  irritation  of  the  bladder  result  which  doubtless  hastened 
the  patient's  death. 

Suprapubic  cystotomy  for  the  removal  of  a  benign  tumor  is  not 
always  indicated.  When  the  patient  bleeds  often  and  loses  much 
blood,  and  the  tumor  increases  in  size,  so  that  the  cavity  of  the  bladder 
is  diminished,  the  operation  is  indicated.  More  frequently  it  comes 
to  pass  that  nature  affords  relief  by  causing  the  expulsion  of  pieces  of 
the  tumor.  The  patients  bleed  very  seldom  and  have  no  pain.  In 
these  latter  cases  suprapubic  cystotomy  seems  to  be  too  serious  a  pro- 
cedure to  warrant  its  performance  for  the  trifling  disturbance  experi- 
enced. Especially  is  this  so  in  the  case  of  old,  decrepit  persons 
in  whom  the  operation  cannot  be  considered  free  from  danger.  In 
addition  to  these  limitations  the  formation  of  fistula? — and  I  see  them 
often  enough  after  the  work  of  the  best  operators — has  to  be  con- 
sidered. 

After  all,  the  indication  for  operative  treatment  of  benign  tumors, 
as  well  for  the  intravesical  method  as  for  the  suprapubic,  depends 
entirely  upon  the  nature  of  the  individual  case.  These  cases  cannot 
be  schematized,  but  on  the  contrary  have  to  be  strictly  individualized. 

Concerning  the  operative  treatment  of  malignant  tumor  only  one 
opinion  can  be  expressed.  Nothing  but  suprapubic  cystotomy  followed 
by  the  extirpation  of  the  tumor,  together  with  a  portion  of  healthy 
bladder- wall,  will  suffice.  There  are  a  few  cases  in  which  part  of  the 
bladder  and,  indeed,  even  the  whole  viscus,  has  been  removed. 

According  to  my  experience,  which  is  founded  on  the  cases  I  have 
operated  on  myself  and  those  I  have  seen  operated  on  by  others, 
good  results  are  seldom  obtained.  If  the  tumor  lies  at  the 
base  of  the  bladder — and  this  is  its  usual  location — the  operation 
is  exceedingly  difficult  and  very  extensive.  It  is  even  more  so  when 
the  ends  of  the  ureters  have  to  be  removed  and  the  stumps 
transplanted.  Even  when  this  is  not  necessary  the  removal  of  a 
malignant  growth  from  the  bladder  is  not  a  gratifying  task.  Here 
as  elsewhere  we  must  operate  in  healthy  tissue,  but  it  is  not  always 


278  DISEASES    OE    THE    URINARY    BLADDER. 

possible  to  do  so  for  the  reason  that  we  cannot  know  how  far  the 
malignant  process  has  infiltrated  the  wall  of  the  bladder.  It  often 
happens  that  we  think  we  are  operating  in  healthy  tissue  and  yet 
leave  remnants  of  the  carcinoma  behind.  Furthermore  it  is  beyond 
our  power  to  tell  whether  infection  has  not  reached  other  organs  by 
way  of  the  lymph-stream. 

These  considerations  are  based  on  practical  experience  derived  from  an 
abundance  of  clinical  material.  A  considerable  number  of  the  patients 
operated  upon  die  from  the  operation  or  its  results.  A  large  number 
of  those  who  survive  operation  have  a  recurrence  of  their  local  disease 
or  die  of  carcinoma  of  other  organs.  In  other  cases  in  which  operation 
seems  to  have  produced  a  cure  fistulas  remain  and  cause  the  patient 
much  distress.  For  these  reasons  I  advise  patients  not  to  be  operated 
on  unless  definite  indications,  such  as  stanchless  haemorrhage  or  intol- 
erable and  uncontrollable  tenesmus,  exist.  Patients  generally  do 
better  and  live  longer  without  than  with  operation. 

INJURIES  OF  THE  BLADDER. 

Injuries  of  the  bladder  are  rare.  If  the  external  tissues  are  injured 
simultaneously  with  the  bladder  we  speak  of  the  condition  as  a  wound 
(stab  wound,  gunshot  wound  of  the  bladder,  while  tears  of  the 
bladder  which  are  not  associated  with  separation  of  the  tissues  which 
lie  above  it,  especially  the  skin,,  are  known  as  ruptures.  An  opening 
into  the  bladder  resulting  from  an  operation  on  another  organ,  and 
one  persisting  after  the  bladder  has  been  opened,  are  not  included  in 
this  category. 

Wounds  of  the  Bladder. — Penetrating  wounds  of  the  bladder  are 
differentiated  according  as  they  do  or  do  not  injure  the  peritoneum. 
Cases  have  been  reported  in  which  the  symptoms  were  so  slight  that 
a  diagnosis  could  not  be  made.  This  is  especially  true  in  cases  in 
which  the  peritoneum  is  not  injured.  In  such  injuries  often  nothing 
but  slight  pain  and  a  constant  desire  to  urinate  are  experienced. 
Attempts  to  void  urine  fail,  the  patient  being  able  to  force  out  only 
a  few  drops  of  blood-stained  fluid  at  a  time.  Very  little  urine  is  ob- 
tained by  catheterization,  although  the  patient  may  not  have  voided 
for  some  time. 

If  the  peritoneum  is  injured  constitutional  symptoms  will  predominate. 
The  patient  is  the  picture  of  collapse.  The  face  is  white  or  ashy  and 
has  an  anxious  sunken  look:  the  pulse  is  smaU  and  frequent,  often 


IXJURIES    OF    THE    BLADDER.  279 

thread-like;  the  sensorium  is  often  disturbed;  the  body  is  covered 
with  sweat  and  the  temperature  is  subnormal. 

Persons  suffering  from  such  an  injur}"  usually  die  unless  prompt 
surgical  intervention  is  practised.  The  prognosis  becomes  even 
worse  if  other  vital  organs,  as  the  intestines,  are  injured.  Less  is  to 
be  feared  from  the  foreign  body  which  has  produced  the  injury,  even 
though  it  remains  in  the  bladder,  an  occurrence  which  is  not  rare 
in  gunshot  wounds.  Infective  material,  such  as  pieces  of  clothing 
or  dirty  skin,  is  frequently  carried  into  the  bladder;  and  in  these 
cases,  although  the  wound  itself  may  not  have  been  fatal,  septic 
infection  develops,  beginning  either  in  the  bladder  and  extending  to 
the  peritoneum,  or  taking  place  as  the  result  of  invasion  of  the  blood 
by  microorganisms. 

Another  exceedingly  dangerous  complication  of  this  injury-  is  infil- 
tration of  urine.  When  the  urine  finds  its  way  toward  the  exterior 
and  forms  a  phlegmon  the  condition  is  not  so  serious,  but  when  it 
infiltrates  toward  the  peritoneum  the  prognosis  is  most  grave. 

From  this  description  it  will  be  seen  that  the  diagnosis  may  be 
either  difficult  or  easy.  In  cases  in  which  there  is  only  slight  laceration 
caused  by  penetrating  instruments,  so  that  the  external  woimd  is 
very  small,  it  may  be  impossible  to  make  an  exact  diagnosis.  It  is 
equally  difficult  if  there  are  injuries  besides  the  tear  of  the  bladder. 
As  an  early  diagnosis  is  of  the  greatest  importance — for  oftentimes 
immediate  surgical  treatment  will  save  the  patient's  life — the  rule 
should  be  to  treat  all  cases  in  which  it  is  at  all  doubtful  whether  the 
bladder  has  been  wounded  exactly  the  same  as  those  in  which  a 
wound  is  known  to  exist. 

Rupture  of  the  Bladder. — In  subcutaneous  lacerations  of  the 
bladder  also,  much  depends  upon  whether  the  peritoneum  is  injured 
or  remains  intact.  They  are  almost  always  caused  by  violence,  such 
as  a  thrust,  a  blow,  a  fall,  or  the  passage  of  a  wagon  over  the  hypo- 
gastrium.  If  the  bladder  is  empty,  subcutaneous  rupture  seldom  or 
never  occurs.  The  fuller  the  bladder,  the  greater  is  the  likelihood 
of  sudden  violence  producing  rupture.  Very  rarely  the  bladder  may 
be  burst  when  it  is  over  distended  by  an  irrigation  given  under  high 
pressure.  Finally,  puncture  with  a  catheter  or  lithotrite  must  be 
mentioned   as  causes,   which,  however,   are  exceedingly  rare. 

The  symptoms  may  at  first  be  ill-defined.  Usually  other  injuries 
have  been  sustained,  and  thus  it  may  happen  that  the  vesical  injury 


280  DISEASES    OF    THE    URINARY    BLADDER. 

will  escape  detection.  Micturition,  however,  is  difficult  or  impossible. 
Violent  strangury  ensues,  but  the  efforts  to  void  are  negative,  or  result 
merely  in  the  expulsion  of  a  little  bloody  urine.  Upon  catheterization 
blood-stained  urine  or  pure  blood  is  obtained.  If  the  line  of  rupture 
becomes  closed  superficially,  it  may  happen  that  a  considerable  quantity 
of  urine  will  be  withdrawn  by  the  catheter,  a  circumstance  which 
may  readily  be  erroneously  interpreted  to  mean  that  no  rupture  of  the 
bladder  has  taken  place. 

This  error  may  prove  most  fatal.  The  superficial  closure  generally 
gives  way,  and  unless  interference  be  soon  practised,  rapidly  spreading 
infiltration  of  urine  occurs.  The  prevesical  tissue  becomes  filled 
with  decomposing  urine.  The  phlegmonous  inflammation  affects 
the  entire  pelvic  cellular  tissue,  extending  to  the  rectum,  the  peri- 
toneum, the  abdominal  walls,  the  testicles,  the  perineum,  the  thighs 
or  buttocks,  rendering  the  affected  parts  emphysematous  and  dis- 
colored. Even  when  this  condition  obtains,  timely  intervention  may 
ward  off  danger,  but  unless  operation  is  done  at  once  general  infec- 
tion, manifested  by  chills  and  progressive  weakness,  usually  follows 
and  soon  causes  death. 

If  the  peritoneum  is  injured  the  symptoms  of  profound  shock  are 
usually  present  from  the  first.  The  pinched  face  with  its  anxious, 
restless  expression,  the  fleeting  pulse,  the  cold  sweat,  and  the  general 
prostration  are  signs  which  make  this  condition  evident.  The  symp- 
toms of  septic  peritonitis  soon  develop.  The  distended,  sensitive 
abdomen,  the  small,  thread-like  pulse,  together  with  hiccough  and 
vomiting  leave  no  doubt  as  to  the  seriousness  of  the  condition. 

The  treatment  of  wounds  and  subcutaneous  rupture  of  the  blad- 
der is  surgical.  We  must  not  be  deceived  by  the  apparent  good  con- 
dition of  the  patient  nor  be  content  with  the  introduction  of  a  per- 
manent catheter.  In  the  meantime  infiltration  of  urine,  irreparable 
as  to  its  consequences,  may  take  place  and  fatal  septic  peritonitis 
supervene. 

If  the  wound  be  extraperitoneal  suprapubic  section  will  suffice, 
the  bladder  being  opened  and  drained  until  it  is  evident  that  there  is 
no  longer  danger  of  infection  taking  place  through  the  wound,  after 
which  sutures  may  be  introduced.  In  some  cases  the  bladder  can 
be  drained  through  the  laceration  or  rupture.  In  others  it  will  be 
possible  to  suture  the  wound  at  once. 

If  the  injury  is  intraperitoneal  immediate  laparotomy  according 


PARASITES    OF    THE    BLADDER.  251 

to  the  usual  rules  of  surgery  is  indicated.  The  tear  in  the  peritoneum 
and  the  vesical  wound  are  both  sutured,  and  a  catheter  is  fastened 
into  the  urethra.  The  chance  of  saving  persons  who  have  sustained 
laceration  or  rupture  is  greater  in  extraperitoneal  wounds  than  in 
intraperitoneal.  In  both  instances,  however,  timely  intervention  will 
save  a  life  which  otherwise  would  certainly  be  lost. 

PARASITES  OF  THE  BLADDER. 

In  this  country  parasitic  diseases  of  the  bladder  are  rare,  although 
with  the  increased  relations  between  tropical  lands  and  Europe  [and 
America  also]  they  are  becoming  more  common  than  they  formerly 
were.  Three  kinds  of  parasites  have  been  found  in  the  human  bladder: 
t.  the  echinococcus;  2.  the  filaria  sanguinis  hominis;  3.  the  distoma 
haematobium. 

Primary  echinococcus  disease  of  the  bladder  is  exceedingly  rare, 
the  parasite  usually  descending  from  the  kidney  by  way  of  the  ureter, 
or  boring  its  way  into  the  bladder  from  the  pelvic  cellular  tissue. 

Unless  the  characteristic  cysts  or  the  hooklets  contained  therein 
are  voided  with  the  urine,  cystoscopy  is  the  only  means  by  which 
a  positive  diagnosis  can  be  made.  The  symptoms  are  those  of 
cystitis. 

Treatment  consists  in  opening  and  obliterating  the  primary  cyst. 

The  filaria  sanguinis  hominis,  which  belongs  to  the  group  of 
nematodes,  occurs  only  in  the  tropics  (Egypt  and  Brazil),  but  it  has 
been  brought  to  Europe  [and  the  United  States]  by  persons  coming 
from  these  regions.  Under  the  microscope  the  parasites  are  seen  to  be 
cylindric  snake-like  bodies,  which  are  either  enveloped  in  a  fine  mem- 
brane or  lie  coiled  up  in  an  oval  capsule.  Elliptical  ova  are  also 
found  in  the  urine. 

The  parasites  invade  the  kidneys  and  give  a  milky  appearance  to 
the  urine;  this  condition  is  called  chyluria,  or  if  blood  also  be  present, 
haematochyluria.  When  it  invades  the  bladder  symptoms  of  inflam- 
mation arise,  such  as  pain,  strangury,  haemorrhage,  and  also  retention 
of  urine.  If  the  patient  goes  to  a  climate  in  which  the  parasite  does 
not  occur,  the  organisms  are  usually  passed  with  the  urine  and  spon- 
taneous cure  takes  place. 

The  distoma  haematobium,  discovered  by  Bilharz,  and  for  this 
reason  also  called  Bilharzia  hasmatobia,  is  a  trematode  parasite  which 
very  frequently  infects  the  inhabitants  of  Egypt  and  the  African  coast 


252  DISEASES    OF    THE    URINARY    BLADDER. 

(Natal  and  the  Cape).  The  embryos,  which  live  in  the  water,  gain 
access  to  the  digestive  tract  and  force  their  way  into  the  portal  vein, 
and  thence  through  the  vesical  veins  into  the  bladder,  where,  together 
with,  their  ova,  they  are  found  in  large  numbers. 

The  distoma  itself  is  a  cylindrical  body  having  rounded  ends  and 
measuring  about  i  cm.  The  ova  are  elliptical  in  form  and  have  a 
terminal  spine. 

They  cause  frequent  haemorrhage,  strangury  and  pain.  If  their 
number  is  small  haemorrhage  may  be  absent,  or  only  microscopic 
traces  of  blood  be  present.  Pus  is  present  and  makes  the  urine  turbid. 
It  is  characteristic  of  this  disease  for  outbursts  of  severe  haemorrhage 
accompanied  by  tenesmus  and  pain  to  alternate  with  periods  of  free- 
dom from  bleeding. 

Treatment  cannot  be  directed  to  removal  of  the  cause;  it  must  be 
confined  to  checking  haemorrhage,  and  for  this  purpose  irrigation 
with  nitrate  of  silver  solution  1:1000-1:500  may  be  used,  and  a 
catheter  fastened  into  the  bladder 

VALVES  AT  THE  NECK  OF  THE  BLADDER. 

Under  the  term  valves  or  strands  at  the  neck  of  the  bladder  there 
has  been  described  an  altered  condition  at  the  entrance  of  the  viscus 
which  is  of  some  clinical  importance.  This  condition  is  quite  different 
than  the  projections  into  the  bladder  caused  by  hypertrophy  of  the 
prostate,  and  the  latter  will  receive  special  consideration  in  the  chapter 
on  prostatic  hypertrophy.  The  condition  now  under  consideration  has 
no  connection  with  enlargement  of  the  prostate,  although  it  produces 
symptoms  similar  to  those  observed  in  this  affection. 

There  are  two  kinds  of  these  projections,  one  due  to  muscular  over- 
growth and  the  other  to  hypertrophy  of  the  mucous  membrane.  In  the 
first  form  there  is  a  thickening  of  the  muscular  fibers  at  the  neck  of 
the  bladder  forming  an  elevation  at  the  internal  meatus;  in  the  other 
form  there  is  a  proliferation  of  the  mucous  membrane  assuming  a 
valvular  or  villous  arrangement,  which  likewise  interferes  with  mic- 
turition. 

Although  the  latter  form  may  be  accounted  for  by  the  occurrence 
at  some  previous  time  of  a  proliferating  inflammatory  process,  no 
explanation  can  be  offered  for  the  development  of  the  muscular  over- 
growth. Both  forms  occasionally  cause  disturbances  of  micturition, 
as  the  result  of  which  a  more  or  less  severe  retention  of  urine  occurs, 


ULCER    OF    THE    BLADDER.  283 

having  all  the  characteristics  of  that  form  due  to  hypertrophy  of  the 
prostate.  Diagnosis  can  be  made  only  by  a  consideration  of  the  com- 
bined results  obtained  from  the  clinical  phenomena,  rectal  palpation, 
and  cystoscopic  examination. 

As  to  treatment  regular  evacuation  of  the  bladder  should  be  secured 
by  aseptic  catheterization.  Trendelenburg  cured  one  of  these  cases 
by  suprapubic  cystotomy  and  incision  of  the  projection. 

ULCER  OF  THE  BLADDER. 

Before  the  perfection  of  the  cystoscope  little  was  known  concerning 
ulcers  of  the  bladder.  Clinically  they  could  not  be  recognized,  and 
they  were  observed  postmortem  in  association  with  other  affections 
of  the  bladder.  Now,  thanks  to  the  perfection  of  our  methods  of 
examination,  a  change  has  taken  place,  and  we  are  able  to  observe 
clinically  a  whole  series  of  vesical  ulcers. 

The  most  common  ulcers  are  those  met  with  in  severe  cystitis. 
In  both  acute  and  chronic  cystitis,  but  especially  in  the  latter,  careful 
cystoscopic  examination  will  sometimes  reveal  a  circumscribed  depres- 
sion in  the  vesical  mucosa.  This  depression,  which  usually  presents 
a  white  coating,  is  undoubtedly  an  ulceration.  Progressive  improve- 
ment and  final  healing  of  the  ulcer  in  response  to  appropriate  treat- 
ment can  be  observed  through  the  cystoscope.  Generally  these  lesions 
are  found  in  bladders  which  have  been  severely  infected,  and  in  which 
multiple  and  diffuse  pathic  changes  have  taken  place,  the  ulceration 
being  observed  in  isolated  patches.  This  form  of  cystitis  has  commonly 
been  called  diphtheritic  and  the  same  term  has  also  been  applied  to 
the  associated  ulcers,  but  there  is  no  special  reason  why  this  nomen- 
clature should  be  adhered  to,  inasmuch  as  any  violent  infection  of  the 
bladder  may  occasionally  lead  to  ulceration. 

It  is  well  known  that  ulcers  are  produced  by  tuberculosis  and  tumors. 
Ulceration  of  a  tumor,  however,  is  not  a  true  ulcer.  Tuberculous 
ulcers  have  already  been  considered.  The  fact  that  there  is  nothing 
characteristic  about  them  will,  however,  bear  repetition  in  this  place. 
Demonstration  of  the  tubercle  bacillus,  contraction  of  the  bladder, 
and  other  changes  will  confirm  the  diagnosis. 

Another  form  of  vesical  ulcer  is  that  due  to  traumatism.  I  have 
frequently  had  the  opportunity  of  observing  them,  and  have  never  seen 
one  caused  by  a  calculus,  although  I  often  come  upon  the  declara- 
tion that  the  pressure  of  a  stone  can  produce  circumscribed  necrosis 


284  DISEASES    OF    THE    URINARY    BLADDER. 

of  the  vesical  mucosa.  Unskillful  catheterization  or  litholapaxy,  as 
well  as  clumsy  cystoscopy  may,  however,  lead  to  ulceration,  as  may 
also  injury  inflicted  by  the  point  of  an  awkwardly  introduced  reten- 
tion-catheter. The  most  common  cause  is  unskilful  cystoscopy,  so  that 
I  believe  myself  to  be  justified  in  using  the  term  cystoscopic  ulcer. 

I  have  never  seen  an  abscess  of  the  bladder- wall  which  broke  exter- 
nally lead  to  the  formation  of  an  intravesical  ulcer,  although  paravesical 
disease,  for  example,  a  parametritic  exudate,  may  rupture  into  the 
bladder  and  cause  ulceration. 

The  much  disputed  simple  ulcer  of  the  bladder,  which  may  be 
compared  to  gastric  ulcer,  is  a  reality.  I  am  familiar  with  several 
instances  in  which  a  circumscribed  ulcer  of  the  bladder  developed 
without  demonstrable  cause.  The  symptoms  of  cystitis  present  in 
these  cases  were  not  pronounced  enough  to  account  for  ulceration. 
As  in  gastric  ulcer,  so  here  must  we  assume  that  embolism  or  throm- 
bosis of  a  blood-vessel  is  responsible  for  the  formation  of  the  ulcer. 

I  am  unable  to  say  whether  syphilitic  ulcers  of  the  bladder  exist. 
I  have  never  observed  any,  but  I  see  no  reason  why  a  sloughing  gumma 
might  not  form  an  ulcer  in  the  bladder  as  well  as  in  any  other  part 
of  the  body. 

Special  symptoms  do  not  occur  in  ulcer  of  the  bladder  for  the  reason 
that  the  lesions  almost  never  exist  alone.  Pus  and  blood  in  the  urine, 
associated  with  pain  and  strangury,  are  the  usual  manifestations. 

The  treatment  is  the  same  as  has  been  outlined  for  cystitis,  tuber- 
culosis, and  tumors.  A  word  of  warning  must  be  sounded  against 
attempts  to  produce  a  cure  by  cauterizing  the  ulcer. 

DIVERTICULA  AND  HERNIA  OF  THE  BLADDER. 

The  term  diverticulum  of  the  bladder  is  applied  to  a  condition  in 
which  bulging  of  the  bladder-wall  occurs,  involving  either  the  entire 
thickness  of  the  wall  or  merely  a  part  of  it,  as  for  example,  the  mucous 
membrane.  English  applies  the  term  diverticulum  to  those  expansions 
which  affect  the  entire  wall,  and  calls  protrusions  of  the  mucous  mem- 
brane through  the  muscular  layer  pouches  or  cells. 

A  clinical  distinction  must  be  made  between  congenital  and 
acquired  diverticula.  Cystoscopy  enables  us  to  make  this  distinction. 
Congenital  diverticula  have  a  sharply  defined  border  and  a  round  or 
oval  opening  which  looks  like  a  hole  in  a  tense  membrane.     Acquired 


DIVERTICULA    AND    HERNIA    OF    THE    BLADDER.  285 

diverticula  have  less  regular  boundaries,  occurring  as  longitudinal, 
round,  or  triangular  clefts,  the  edges  of  which  are  formed  by  projecting 
trabecular.  The  congenital  diverticula  are  much  deeper  than  the 
acquired,  so  that  their  posterior  wall  cannot  be  seen ;  the  fundus  looks 
black.  Acquired  diverticula  are  shallow  and  their  posterior  boundary 
can  usually  be  seen;  it  varies  in  color  from  red  to  dark  gray. 

Diverticula  vary  greatly  as  to  their  number.  The  congenital  variety 
are  usually  single,  although  now  and  then  two  or  three  are  found.  The 
acquired  variety  may  be  so  numerous  that  the  bladder  may  have  the 
appearance  of  a  net-work.  The  greater  their  number  the  less  their 
extent.  The  thickness  of  their  wall  varies.  In  the  congenital  variety 
it  generally  includes  mucous  membrane,  muscle  and  its  covering. 
In  the  acquired  form  the  wall  is  either  composed  of  mucous  membrane 
alone,  or  there  may  be  a  few  muscle  fibers  covering  the  membrane. 

The  development  of  this  condition  is  due  to  some  obstacle  to  the 
free  outflow  of  urine  (stricture,  hypertrophy  of  the  prostate,  partial 
paralysis,  arteriosclerosis).  Owing  to  the  increased  contractions  of 
the  bladder  necessary  to  overcome  the  increased  resistance,  the  muscle 
fibers  are  forced  asunder  and  the  mucous  membrane  protrudes  between 
them  like  the  sac  of  a  hernia. 

Clear  urine  or  pus,  as  well  as  calculi,  will  be  found  in  these  diverti- 
cula and  pouches.  The  stones  sometimes  fall  out  of  the  diverticula 
when  the  patient  moves  about.  They  may,  however,  remain  in  the 
diverticula  and  become  encapsulated,  becoming  so  large  as  the  result 
of  increased  deposit  of  urinary  salts  upon  them  that  they  cannot  pass 
through  the  opening  between  the  diverticulum  and  the  bladder. 

Exact  diagnosis  is  impossible  without  the  cystoscope.  They  cannot 
be  palpated  and  they  produce  no  symptoms.  When  pressure  over  a 
bladder  which  has  been  thoroughly  irrigated  causes  a  sudden  outflow 
of  pus,  and  the  possibility  of  its  coming  from  the  kidneys  can  be 
excluded,  it  is  probable  that  a  diverticulum  of  the  bladder  exists. 
Under  these  circumstances  decisive  information  can  be  immediately 
obtained  by  cystoscopy. 

Special  treatment  is  not  required  for  diverticula.  If  cystitis  develops 
they  can  be  cleansed  by  irrigation,  especially  if  the  bladder  be  well 
filled.  Care  must  be  taken,  however,  not  to  use  enough  pressure 
to  cause  rupture  of  the  pouch.  Only  as  much  fluid  should  be  injected 
as  the  patient  can  endure  without  its  causing  urgency  to  void. 

Very  rarely  a  process  of  peritoneum  becomes  invaginated  in  the 


286  DISEASES    OF    THE    URINARY    BLADDER. 

cleft  formed  by  separation  of  the  muscular  fibers,  in  the  same  manner 
that  the  mucosa  protrudes  between  them  from  within.  Thus  a  true 
hernial  sac  is  formed  into  which  intestine  may  escape.  The  diag- 
nosis of  this  rare  condition  is,  of  course,  impossible. 

Prolapse  of  the  bladder  through  the  urethra,  a  condition  which  is 
found  only  in  females,  is  called  urethral  cystocle.  This  condition 
is  divided,  according  to  its  degree  of  severity,  into  invagination, 
inversion,  and  prolapse;  when  the  bladder- wall  points  outward  into 
the  urethra  it  is  called  invagination,  when  the  bladder  reaches  the 
external  orifice  of  the  urethra  is  it  known  as  inversion,  and  when  the 
bladder  protrudes  from  the  urethra,  forming  a  tumor  covered  with 
mucous  membrane,  it  is  spoken  of  as  prolapse.  Atony  of  the  bladder, 
and  dilatation  of  the  urethra  combined  with  increased  expulsive  force, 
are  to  be  considered  responsible  for  the  development  of  this  abnor- 
mality. Confusion  with  urethrocele  may  readily  occur,  so  that  the 
latter  must  be  excluded  before  making  a  diagnosis.  Treatment 
consists  in  reposition  if  possible,  or  if  not,  in  operation. 

-True  hernia  of  the  bladder  is  a  different  condition  from  the  one 
just  described,  the  bladder  or  a  portion  of  it  protruding  through  a 
hernial  orifice.  It  may  occur  in  any  part  of  the  lower  abdomen  where 
other  herniae  take  place,  but  its  most  common  location  is  in  the  inguinal 
canal.  Even  this  form,  however,  is  rare.  The  bladder  is  either 
adherent  to  other  structures,  with  which  it  has  escaped  into  the  inguinal 
canal,  or  else  fatty  tumors  pull  it  in;  congenital  abnormalities  such  as 
increased  length  of  the  superior  suspensory  ligament  or  of  the  ureters, 
diverticula,  relaxation  of  the  bladder,  etc.,  may  also  be  responsible 
for  the  occurrence  of  this  condition. 

Diagnosis  may  be  exceedingly  difficult  or  even  impossible.  Pro- 
nounced subjective  symptoms  are  not  usually  present.  A  fluctuating 
tumor  is  found  along  the  course  of  the  inguinal  canal  similar  to  that 
which  occurs  in  hydrocele  of  the  cord.  Percussion  of  the  tumor  elicits 
dullness.  When  reduction  is  not  possible  pressure  over  the  swelling 
will  give  rise  to  a  desire  to  urinate.  It  is  not  unusual  for  micturition 
to  be  interrupted  several  times.  The  tumor  is  increased  in  size  by 
protracted  standing,  walking,  and  violent  exertion,  as  well  as  by 
intraabdominal  pressure.  If  other  structures,  for  instance  omentum, 
lie  within  the  hernial  sac  diagnosis  may  be  utterly  impossible.  It 
should  be  remembered  that  calculi  are  comparatively  common  in 
vesical  hernia. 


VARICES    OF    THE    BLADDER.  287 

As  to  treatment,  a  truss  should  be  worn  and  the  bladder  frequently 
catheterized ;  if  no  improvement  follows,  radical  operation,  perhaps 
with  resection  of  the  bladder,  may  be  considered. 

VARICES  OF  THE  BLADDER. 

The  existence  of  varices  of  the  bladder  has  been  denied.  It  has 
been  said  that  the  cases  diagnosticated  as  such  were  in  reality  cases  of 
tumor,  or  some  other  disease  capable  of  producing  haemorrhage.  Al- 
though it  is  true  that  varices  of  the  bladder  are  rarer  than  they  have 
been  supposed  to  be,  I  have,  nevertheless,  demonstrated  their  existence 
both  by  operation  and  by  the  use  of  the  cystoscope.  Tortuous  veins 
of  a  distinct  blue  color  are  seen  near  the  neck  of  the  bladder.  Not 
uncommonly,  too,  ecchymoses  of  the  vesical  mucous  membrane  are 
observed. 

I  have  found  these  dilated  veins  in  the  subjects  of  haemorrhoids,  in 
persons  suffering  from  hypertrophy  of  the  prostate  and  the  local 
engorgement  incident  thereto,  as  well  as  in  those  affected  with  arter- 
iosclerosis of  the  genital  tract,  and  those  suffering  with  disturbances 
of  the  central  nervous  system  (myelitis,  tabes,  paresis)  in  which  there 
is  probably  paralysis  of  the  vasomotor  nerves. 

Usually  the  only  symptom  is  severe  haemorrhage,  which  arises  spon- 
taneously without  any  recognizable  cause  and  continues  without 
producing  pain.  Occasionally  it  is  of  such  severity  as  to  cause  the 
formation  of  large  clots,  as  the  result  of  which  the  bladder  cannot  be 
properly  emptied.  Under  these  circumstances  painful  tenesmus 
occurs.  If  a  catheter  be  introduced  its  eye  becomes  occluded,  so  that 
it  is  very  difficult  to  cleanse  the  bladder.  Removal  of  the  blood-clots 
facilitates  matters. 

I  have  observed  haemorrhage  so  severe  as  to  produce  alarming 
anaemia  and  necessitate  the  performance  of  suprapubic  cystotomy 
in  order  to  control  the  bleeding.  A  milder  method  which  should  be 
tried  first  consists  in  the  introduction  of  a  retention-catheter  and 
irrigation  of  the  bladder  with  strong  silver  solution  (1:1000-1:500), 
or  the  injection  of  100  g.  [about  3  fluid  ounces]  of  Merck's  2%  steril- 
ized solution  of  gelatine.  In  this  manner  the  haemorrhage  can  almost 
always  be  arrested. 

MALFORMATIONS  OF  THE  BLADDER. 

The  bladder  may  be  entirely  absent,  but  the  persons  in  whom  it  is 
not  present  are  usually  so  afflicted  with  other  abnormalities  that  they 


DISEASES    OF    THE    URINARY    BLADDER. 


do  not  survive.  Cases  of  excessive  atrophy  of  the  bladder  have  been 
observed  in  which  the  ureters  emptied  into  the  urethra  or  rectum, 
or  opened  upon  the  abdominal  wall. 

An  exceedingly  rare  condition  is  double  bladder,  which  occurs 
exclusively  in  association  with  other  double  pelvic  organs.  When  the 
bladder  is  divided  into  separate  compartments  by  one  or  more  longi- 
tudinal or  transverse  septa  it  is  spoken  of  as  duplicated  or  lobulated 
bladder.  These  malformations  are  to  be  differentiated  from  congenital 
diverticula,  which,  when  very  large,  may  have  the  appearance  of  double 
or  multiple  bladder. 


Fig.  173. — Exstrophy  of  the  bladder.     B.  Bladder.     E.  Glans  penis.     S.  Scrotum. 

A  very  important  and  much  more  frequent  malformation  is  exstrophy 
of  the  bladder,  or  congenital  cleft,  a  condition  in  which  the  posterior 
wall  of  the  bladder  protrudes  through  an  opening  in  the  abdominal 
wall  and  forms  a  distinct  red  tumor.  The  mucous  membrane  covering 
the  tumor  becomes  continuous  with  the  skin  of  the  abdomen.  Care- 
ful search  will  reveal  the  orifices  of  the  ureters  in  the  region  where 
skin  and  mucous  membrane  meet  (Fig.  173). 

Different  theories  obtain  in  regard  to  the  development  of  this  most 
distressing  malformation.     The  supposition  that  injury  during  intra- 
uterine life  causes  fissure  of  the  bladder,  or  that  the  umbilical  cord 
ying  between  the  legs  of  the  foetus  presses  upon  the  anterior  abdominal 


ANOMALIES    OF    THE    UEACHUS.  289 

wall  and  prevents  its  union  with  the  bladder  has  little  foundation. 
It  is  more  probable  that  the  condition  results  from  some  impediment 
which  hinders  the  union  of  the  lateral  portions  of  the  uro-genital 
cleft,  and  thus  prevents  the  formation  of  the  anterior  wall  of  the  bladder 
and  the  abdominal  parietes. 

There  are  different  degrees  of  exstrophy  varying  from  diastasis  of 
the  abdominal  wall  and  symphysis  pubis,  in  which  the  bladder  is 
covered  by  skin,  to  complete  exstrophy,  which  is  almost  always  asso- 
ciated with  epispadias  {quod  vide). 

The  condition  of  persons  thus  affected  is  most  wretched.  They 
are  constantly  wet  and  diffuse  a  foul,  uriniferous  odor;  owing  to  the 
constant  moisture  eczema  and  other  inflammatory  diseases  of  the 
skin  develop,  and  haemorrhage  from  the  exposed  mucous  membrane 
is  not  at  all  uncommon. 

The  treatment  of  this  malformation  is  purely  surgical,  for  even  the 
greatest  care  and  cleanliness  cannot  keep  life  from  being  a  burden. 
Different  procedures  have  been  tried,  many  of  which  have  now  and 
then  been  crowned  with  success.  Some  have  implanted  the  ureters 
into  the  rectum  or  into  the  epispadic  opening  of  the  penis,  extirpated 
the  bladder,  and  then  closed  the  abdominal  defect  with  sutures  (Son- 
nenberg) ;  others  have  forced  the  edges  of  the  symphysis  together  and 
then  endeavored  to  close  the  opening  in  the  abdomen  (Trendelenburg) ; 
finally,  plastic  operations  have  been  undertaken  for  the  purpose  of 
providing  a  receptacle  for  the  urine  and  closing  the  defect  by  means 
of  flaps.  Mikulicz  constructs  a  bladder  out  of  the  large  intestine. 
[Wood  and  Thiersch  have  also  devised  flap  operations.  More  than 
thirty  years  ago  the  late  Dr.  Frank  Maury,  of  Philadelphia,  operated 
for  exstrophy  of  the  bladder  by  dissecting  a  flap  from  the  perineum 
and  scrotum,  turning  it  over  the  cleft,  and  then  covering  it  by  a  second 
flap  taken  from  the  abdomen.] 

ANOMALIES  OF<:  THE'  URACHUS. 


If  the  urachus,  which  together  with  the  bladder  is  formed  from  the 
allantois,  and  in  extrauterine  life  becomes  the  middle  vesico-umbilical 
ligament,  remains  open,  a  fistula  of  the  urachus  is  formed.  The 
iistulous  canal  may  be  extremely  small  or  it  may  be  as  large  as  a  thread. 
The  cause  of  this  abnormality  is  some  congenital  obstruction  to  the 
passage  of  urine.  If  this  obstruction,  as  for  instance  a  congenital 
phimosis,  be  removed,  it  not  uncommonly  happens  that  the  fistula 

IQ 


290  DISEASES    OF    THE    URINARY    BLADDER. 

heals,  although  in  some  cases  it  becomes  necessary  to  lay  it  open  and 
curette  it,*  or  to  extirpate  it. 

If  an  exudate  is  formed  in  the  patulous  vesico- umbilical  ligament 
a  cyst  develops.  It  is,  however,  very  rare  for  this  to  occur.  The 
diagnosis  of  this  abnormality  is  possible  only  when  it  can  be  positively 
determined  that  the  oval,  fluctuating  tumor,  which  is  fixed  in  the 
median  line  of  the  abdomen  between  the  umbilicus  and  the  bladder, 
is  not  connected  with  other  pelvic  organs  (Ledderhose). 

PREVESICAL  PHLEGMON. 

This  disease  is  entitled  to  description  only  for  the  reason  that  it 
sometimes  occurs  independently  of  suppuration  in  neighboring  organs 
and  tissues,  such  as  the  bladder,  the  seminal  vesicles,  and  the  broad 
ligaments.  Suppuration  of  the  connective  tissue  in  the  space  of  Retzius 
also  occurs  in  association  with  suppuration  in  other  cavities  of  the 
body  due  to  general  infection  through  the  blood-stream  (typhoid 
fever,  puerperal  fever),  as  the  result  of  injury,  or  without  assignable 
cause. 

The  disease  is  characterized  by  disturbance  of  micturition,  which 
is  both  painful  and  more  difficult  than  normal,  and  also  by  a  swelling 
over  the  symphysis,  which,  if  it  becomes  extensive,  may  show  signs 
of  fluctuation.  Resolution  may  take  place  and  the  symptoms  subside, 
or  the  suppurative  process  may  invade  the  neighboring  tissues,  in 
which  case  the  phenomena  of  general  infection — small,  quick  pulse, 
nausea,  vomiting,  and  the  local  manifestations  of  peritonitis — super- 
vene. 

Diagnosis  may  be  difficult,  but  the  use  of  the  sound  will  apprize 
us  that  the  tumor  is  not  in  the  bladder.  Because  of  its  acute  course, 
this  disease  requires  no  differentiation  from  tumors. 

An  early  diagnosis  is  of  great  importance  because  there  is  danger 
of  the  abscess  rupturing  into  the  peritoneal  cavity.  Free  incision  into 
the  seat  of  infection  before  it  has  become  extensive  will  quickly  render 
the  situation  free  from  danger  and  produce  a  cure. 

NEUROSES  OF  THE  BLADDER. 

Our  knowledge  of  the  numerous  affections  of  the  bladder  is  some- 
what obscure.  As  in  other  departments  of  medicine  so  likewise  here 
everything  which  cannot  be  called  something  else  is  termed  a  neurosis. 


NEUROSES    OF    THE    BLADDER.  29 1 

As  a  result  of  our  improved  methods  of  examination  the  diagnosis 
of  vesical  neurosis  has  become  less  common;  but  even  now  it  often 
comes  to  pass  that  cases  in  which  an  objective  basis  for  the  symptoms 
present  might  be  determined  by  the  sense  of  touch  or  sight,  or  by 
changes  in  the  urine,  are  denominated  neuroses;  in  reality  these  con- 
ditions are  only  the  beginning  of  organic  maladies  which  later  cause 
appreciable  objective  changes. 

We  will  preface  our  treatise  on  the  neuroses  of  the  bladder  with  a  des- 
cription of  the  mechanism  of  micturition.  We  distinguish  two  muscles 
of  the  bladder,  the  detrusor1  and  the  the  sphincter,  the  latter  of  which 
has  a  circular  arrangement  of  its  fibers  which  enable  it  to  keep  the 
bladder  closed  when  its  tonicity  is  maintained.  This  closure  of  the 
bladder  is  aided  by  the  so-called  external  sphincter,  or  compressor 
of  the  membranous  portion  of  the  urethra.  If  a  contraction  of  the 
detrusor  is  engendered  by  the  collection  of  urine  in  the  bladder,  aboli- 
tion of  the  tonicity  of  the  sphincter  immediately  follows,  with  the 
result  that  micturition  can  occur.  Thus  the  detrusor  and  sphincter 
have  an  antagonistic  action,  inasmuch  as  the  one  contracts  and  the 
other  relaxes  in  response  to  the  same  stimulus.  While  the  former, 
in  response  to  the  pressure  exerted  by  the  urine,  effectuates  its  expul- 
sion, the  latter  causes  the  neck  of  the  bladder  to  open  so  that  it  can 
flow  out. 

In  explanation  of  these  conditions  it  has  been  assumed  that  there 
are  two  motor  centers  in  the  spinal  cord  which  lie  at  about  the  level 
of  the  third  or  fourth  sacral  nerve.  The  mucous  membrane  of  the 
bladder  is  connected  with  the  brain  by  sensory  nerve-fibers.  The 
brain  transmits  the  impulses  which  it  receives  from  these  fibers  to 
the  motor  centers  in  the  cord.  The  following  schematic  representation 
of  these  relations  is  taken  from  Guterbock's  "Diseases  of  the  Urinary 
Bladder,"  he  in  turn  having  borrowed  it  from  Bramwell  (Fig.  174). 

The  sphincter  muscle  (SM)  is  in  a  state  of  contraction,  the  result 
of  nerve-force  continually  sent  to  it  from  its  tonic  center  (CSM)  in  the 
spinal  cord,  through  sm,  as  indicated  by  the  arrow. 

V  =  the  bladder,  which  is  represented  as  empty.  SM,  the  sphincter 
muscle.  DM,  detrusor  muscle.  AM,  abdominal  muscles,  mm, 
mucous  membrane  of  bladder.  B,  the  brain.  CDM,  spinal  center 
for  the   detrusor    muscle.     CSM,    spinal   center   for   the    sphincter 

1  The  term  detrusor  is  applied  to  the  musculature  of  the  body  of  the  bladder. 


292 


DISEASES    OF    THE    URINARY    BLADDER. 


muscle.  S,  sensory  fiber  proceeding  from  the  mucous  membrane  of 
bladder  up  to  the  spinal  cord  and  brain,  dm,  motor  nerve  from  the 
spinal  center  for  the  detrusor  muscle,  sm,  motor  nerve  from  the 
spinal  center  for  the  sphincter  muscle,  b,  nerve  filament  proceeding 
from  the  brain  to  the  spinal  centers  of  the  detrusor  and  sphincter 


Fig.  174. — The  mechanism  of  urination.     (Bramwell). 


muscles.  An  impulse  from  the  brain  through  b  inhibits  the  sphincter 
center  (dotted  line)  and  excites  the  detrusor  center,  -b",  nerve 
filament  proceeding  from  the  brain  to  the  spinal  centers  of  the  sphinc- 
ter and  detrusor  muscles.  An  impulse  along  b"  strengthens  the 
sphincter  and  inhibits  the  detrusor  center,  b' ,  nerve]  filament  from 
the  brain  to  the  abdominal  muscles. 


NEUROSES    OF    THE    BLADDER. 


293 


Fig.  175  is  a  diagrammatic  representation  of  the  parts  concerned 
in  the  process  of  micturition  while  in  action. 

The  bladder  (V)  is  full  of  urine.  The  mucous  membrane  (mm) 
is  stimulated,  an  impulse  is  generated,  and  is  carried  by  the  sensory 
(centripetal)  nerve  (S)  to  the  brain  (B),  and  to  the  spinal  centers  for 


Fig.  175. — The  mechanism  of  urination.     (Bramwell). 


the  detrusor  (CDM),  and  sphincter  (CSM).  From  the  brain  an 
impulse  is  sent  (1)  along  the  nerve  (b)  which  strengthens  the  action 
of  the  detrusor  center  (CDM),  and  inhibits  the  action  of  the  sphinc- 
ter center  (CSM);  (2)  along  the  nerve  (b')  which  throws  the  abdomi- 
nal muscles  (AM)  into  action. 

The  reflex  impulse  which  has  passed  from  the  mucous  membrane 


294  DISEASES    OF    THE    URINARY    BLADDER 

of  the  bladder  to  the  spinal  cord,  excites  the  action  of  the  detrusor 
center,  and  inhibits  the  action  of  the  sphincter  center. 

The  final  result  is  contraction  of  the  detrusor  muscle  (DM), 
relaxation  of  the  sphincter  muscle,  (SM) ;  and  the  expulsion  of  urine. 
The  arrows  indicate  the  direction  of  the  nerve  currents. 

The  conditions  upon  which  retention  of  urine  of  nervous  origin 
depend  is  well  represented  by  these  diagrams.  An  impulse  from  the 
brain  is  sent  to  the  detrusor  center  inhibiting  its  action;  or  else  the 
same  stimulus  increases  the  action  of  the  sphincter  center,  or  perhaps 
both  effects  are  produced.  The  result  is  that  the  sphincter  closes 
so  firmly  that  the  detrusor  cannot  overcome  its  resistance,  and  the  in- 
dividual is  unable  to  void  his  urine. 

Theoretically  we  would  expect  diseases  due  to  irritability  or  paralysis 
of  the  sensory  and  motor  nerves.  Practically,  however,  we  only  have 
to  do  with  the  following  conditions:  i.  irritability  of  the  sensory 
nerves;  2.  irritability  of  the  motor  nerves;  3.  paralysis  of  the  motor 
nerves;  4.  atony  of  the  bladder,  a  malady  which  although  it  really  has 
nothing  to  do  with  nervous  diseases,  is  usually  classified  among  them. 

I.    IRRITABILITY    OF    THE    SENSORY    NERVES    OF    THE    BLADDER. 

There  is  a  malady  dependent  upon  irritability  of  the  sensory  nerves 
of  the  bladder,  which  because  of  its  obscurity  and  its  want  of  objective 
symptoms  has  received  various  names,  among  which  may  be  mentioned 
hyperesthesia  vesicae,  cystalgia,  irritable  bladder,  and  neurosis  or 
neuralgia  of  the  bladder. 

This  disease  is  characterized  by  total  abscence  of  objective  changes. 
Cystitic  phenomena  cannot  be  detected  either  by  urine  analysis  or  by 
cystoscopy.  Urgency  of  urination,  which  at  times  becomes  most 
imperative,  is  present.  The  patient  is  compelled  to  void  his  urine 
every  half  hour,  or  it  may  be  every  fifteen  minutes,  at  times  expelling 
a  large  quantity,  at  other  times  very  little.  The  circumstance  which 
separates  this  strangury  from  all  other  forms  is,  that  it  is  present  only 
during  the  day.  At  night  the  patients  sleep  without  having  to  urinate 
more  frequently  than  a  well  person. 

Pain  is  commonly  present,  and  it  may  occur  simultaneously  with 
micturition  or  exist  independently  thereof.  The  pain  present  between 
the  acts  of  micturition  is  situated  over  the  bladder  and  radiates  toward 
the  perineum,  thighs  and  anus;  that  which  occurs  during  micturition 


NEUROSES    OF    THE    BLADDER.  295 

is  ordinarily  located  in  the  penis,  and  not  uncommonly  is  felt  at  the  end 
of  the  organ. 

Another  important  symptom  is  polyuria.  As  much  as  four  liters 
[one  gallon]  of  urine  may  be  voided  in  a  day.  It  is  as  light  as  water, 
being  a  true  "spastic  urine"  (urina  spastica).  The  introduction  of 
an  instrument  shows  that  the  bladder  is  not  so  sensitive  as  it  is  in 
diseases  having  a  material  basis,  such  as  calculi,  inflammation,  etc. 
The  capacity  of  the  bladder  is  well  preserved,  so  that  from  300  cc.  to 
500  cc.  [10  to  16  fluid  ounces]  of  water  can  be  injected  into  it  without 
causing  a  desire  to  void.  The  strangury  and  pain  are  very  obstinate 
and  do  not  readily  yield  to  treatment.  This  is  one  of  the  character- 
istics of  the  disease. 

In  respect  to  diagnosis  it  may  be  repeated  that  all  cases  in  which 
any  material  cause  for  strangury  or  pain  can  be  demonstrated  do  not 
come  under  this  heading.  In  the  female  prolapse  of  the  vaginal  wall 
or  displacement  of  the  uterus  may  give  rise  to  these  symptoms.  Hasm- 
orrhoids,  disease  of  the  pelvis  of  the  kidney,  and  chronic  prostatitis 
may  also  produce  them,  but  in  contradistinction  to  those  produced  by 
irritability  of  the  bladder  they  disappear  when  the  cause  is  removed. 

Contraction  of  the  meatus  urinarius  is  the  sole  physical  abnormality 
which  I  have  ever  been  able  to  hold  responsible  for  this  condition. 
In  such  cases  the  neurosis  is  easily  cured  by  slitting  the  meatus  and 
keeping  it  open  by  means  of  proper  sutures. 

Even  in  those  cases  in  which  no  cause  can  be  determined  the  symp- 
toms may  often  be  alleviated  or  controlled,  although  they  are  likely 
to  recur.  Hot  sitz-baths,  the  use  of  the  thermophore  either  externally 
or  in  the  rectum,  morphine  or  belladonna  internally,  or  better  still 
small  clysters  composed  of  antipyrine,  phenacetine,  or  pyramidon, 
with  10  to  20  drops  of  laudanum,  exert  a  favorable  effect.  Occasion- 
ally good  results  are  obtained  by  electricity,  one  electrode  being  placed 
over  the  bladder  and  the  other  on  the  perineum;  or  one  may  be  intro- 
duced into  the  bladder,  which  has  previously  been  filled  with  sterile 
water,   and  the  other  laid  over  the  bladder. 

2.    IRRITABILITY    OF    THE    MOTOR    NERVES    OF    THE    BLADDER. 

The  disease  caused  by  motor  irritability'  of  the  bladder  has  also 
been  variously  denominated.  Spasm  of  the  neck  of  the  bladder, 
vesical  spasm,  (cysto  spasmus,)  stammering  of  the  bladder,  and 
contracture  of  the  neck  of  the  bladder  are  some  of  the  names  which 


296  DISEASES    OF    THE    URINARY    BLADDER. 

have  been  applied  to  it.  An  attempt  has  been  made  to  distinguish 
spasm  of  the  neck  of  the  bladder  from  spasm  of  the  body,  and  to 
differentiate  between  a  transitory  and  permanent  spasm.  That 
which  is  generally  meant  by  the  term  spasm  of  the  bladder  is  a  spastic 
contraction  of  the  neck  of  the  viscus.  Contraction  of  the  body  of  the 
organ  will  be  considered  under  enuresis. 

Spasm  of  the  bladder  is  characterized  by  difficulty  of  micturition. 

The  bladder  seems  as  though  closed,  the  stream  of  urine  is  as  small 
as  if  a  tight  stricture  were  present,  and  at  times  it  is  interrupted; 
at  other  times  the  patient  can  expel  only  a  few  drops  of  urine.  These 
symptoms  exist  without  there  being  any  narrowing  of  the  urethra 
or  any  disease  of  the  prostate.  The  introduction  of  a  sound  readily 
shows  that  neither  of  the  latter  conditions  are  present. 

One  result  of  these  powerful  contractions  of  the  bladder  is  the 
retention  of  a  large  quantity  of  urine,  which  produces  pain  in  the 
suprapubic  region  and  the  penis.  The  condition  is  analogous  with 
retention  due  to  stricture,  or  to  displacement  of  the  neck  of  the  bladder 
by  an  enlarged  prostate. 

It  is  unusual  for  the  peripheral  portions  of  the  motor  nerves 
to  be  affected,  it  being  generally  the  motor  centers  in  the  spinal  cord, 
or  their  centrifugal  tracks  which  are  at  fault.  Thus  it  is  that  the  con- 
dition is  observed  in  myelitis,  spondylitis,  tabes,  multiple  lateral 
sclerosis,  and  hysteria,  as  well  as  in  association  with  tumors  which 
press  upon  the  cord.  The  vesical  spasm  to  which  we  alluded  under 
stricture  of  the  urethra  is  due  to  irritability  of  the  peripheral  tracks. 

Those  cases  which  have  been  referred  to  as  stammering  of  the 
bladder  are  not  caused  by  organic  disease,  but  by  transitory  irrita- 
bility of  the  motor  nerves  supplying  the  sphincter,  or  of  the  motor 
centers.  The  subjects  of  this  complaint  cannot  void  their  urine 
freely,  but  pass  it  a  little  at  a  time,  micturition  being  frequently  inter- 
rupted. This  comes  to  pass  especially  when  they  try  to  urinate  in 
the  presence  of  others;  then  their  power  to  void  may  fail  entirely. 
Even  when  alone  they  experience  great  difficulty  and  are  forced  to 
make  strenuous  efforts  even  to  partly  evacuate  their  bladder.  At 
times,  however,  they  can  urinate  with  the  utmost  freedom. 

The  treatment  of  these  vesical  contractions  and  spasms  is  identical 
with  that  of  the  disease  by  which  they  are  produced.  It  is  more 
satisfactory  than  one  would  be  led  to  believe  from  the  nature  of  the 
causative  maladies.     Spasm  due  to  stricture  is  readily  overcome  by 


NEUROSES    OF    THE    BLADDER.  297 

passing  sounds,  and  that  due  to  tabes  and  spastic  spinal  paralysis 
is  notably  benefited  by  the  same  procedure.  I  have  seen  a  great 
many  who  could  not  pass  a  drop  of  urine  become  able  to  urinate  after 
a  short  period  of  catheterization.  Recurrences  are  bound  to  take 
place,  for  the  reason  that  it  is  almost  impossible  to  overcome  the 
primitive  cause  of  the  evil. 

3.  PARALYSIS  OF  THE  MOTOR  NERVES  OF  THE  BLADDER 
(PARALYSIS  AND  PARESIS  OF  THE  bladder). 

Paralysis  of  the  motor  tracks  which  lead  to  the  bladder  may  affect 
the  peripheral  nerves  or  the  central  paths  of  conduction  and  the  reflex 
centers.  The  results  are  the  same.  If  only  the  tracks  which  go  to 
the  detrusor  or  the  reflex  centers  governing  it  are  affected,  complete 
retention  of  urine  follows.  The  detrusor  is  powerless  to  expel  the 
urine,  but  the  tonicity  of  the  sphincter  remains  unimpaired.  If  the 
latter  muscle  loses  its  tonicity  then  incontinence  is  the  result,  and  the 
urine  constantly  dribbles  away.  That  portion  of  the  urine,  however, 
which  lies  below  the  level  of  the  sphincter  usually  remains  in  the 
bladder.  Under  these  circumstances  incomplete  retention  of 
urine  results.  Thompson  has  correctly  designated  this  condition 
as  overflow  of  the  bladder.  As  soon  as  enough  urine  collects  to 
reach  to  the  height  of  the  sphincter  a  portion  of  it  flows  out  through 
the  relaxed  muscle.  It  is  self-evident  that  persons  thus  affected  can 
urinate  only  when  their  bladder  is  full,  and  then  only  in  the  sitting 
posture,  inasmuch  as  they  expel  the  urine  above  the  level  of  the  sphinc- 
ter by  the  help  of  abdominal  pressure. 

Very  often  merely  partial  paralysis  is  present.  Not  all  the  fibers 
or  tracks  are  diseased,  so  that  the  power  of  the  bladder  to  expel  urine 
is  not  abolished,  but  only  diminished.  A  portion  of  the  urine  is  voided, 
but  more  or  less  is  retained  (paresis  of  the  bladder).  The  power  of 
the  detrusor  is  measured  by  the  quantity  of  urine  remaining  in  the 
bladder  after  micturition;  this  quantity  is  called  the  residual  urine. 

If  the  tonicity  of  the  sphincter  is  fairly  preserved,  but  the  detrusor 
paralyzed,  a  considerable  quantity  of  urine  will  collect  in  the  bladder. 
Although  some  of  it  is  voided  involuntarily,  severe  strangury  may 
nevertheless  occur,  from  which  the  patient  can  relieve  himself  only 
by  making  forcible  efforts  to  urinate.  This  condition  has  been  named 
ischuria  paradoxa. 


298  DISEASES    OF    THE    URINARY    BLADDER. 

These  paralyses  of  the  vesical  nerves  may  be  caused  by  trauma 
(fracture  of  the  vertebral  column),  in  which  case  they  are  character- 
ized by  their  acute  onset.  Compression  of  the  cord  by  haemorrhage 
or  exudate,  myelitis,  hemiplegia,  general  progressive  paralysis,  tabes, 
and  hysteria  may  all  cause  complete  or  partial  paralysis  of  the  bladder. 
The  term  jaux  urinaires  has  been  applied  by  the  French  to  persons 
affected  with  these  latter  forms  of  paralysis. 

It  is  extremely  important  to  remember  that  involuntary  discharge 
of  urine  dependent  upon  partial  paralysis  of  the  bladder  is  often  an 
initial  symptom  of  tabes,  and  that  the  diagnosis  of  the  latter  disease 
may  at  times  be  made  solely  from  the  vesical  symptoms. 

Treatment  is  to  be  directed  to  the  cause  of  the  trouble.  If  the 
central  disturbance  can  be  overcome  the  vesical  weakness  will  disappear. 
The  prognosis  is  by  no  means  bad  in  all  cases.  Patients  frequently 
regain  complete,  or  at  least  partial  power,  of  voiding  their  urine.  It 
is  probable  that  this  is  brought  about  by  increase  of  strength  in  the 
nerve  tracks  which  have  remained  free  from  disease.  Therefore 
the  object  of  treatment  must  be-  to  preserve  as  much  as  can  be  pre- 
served. 

The  bladder  must  be  relieved  by  regular  catheterization,  which, 
must  be  practised  under  strict  antiseptic  precautions,  as  these 
cases  of  vesical  paralysis  are  exceedingly  susceptible  to  infection  for 
the  reason  that  the  residual  urine  affords  an  excellent  culture-medium 
for  microorganisms.  It  is  also  a  good  idea  to  use  slightly  irritating 
vesical  injections,  for  example,  nitrate  of  silver  1:5000-1:1000  in 
conjunction  with  catheterization. 

Large  doses  of  strychnine  are  to  be  given,  and  electricity  in 
the  form  of  the  faradic  and  constant  current  should  also  be  tried. 
One  electrode  is  placed  on  the  perineum  or  over  the  bladder  above 
the  symphysis  and  the  other,  in  the  form  of  a  metal  sound  covered, 
except  as  to  its  tip,  with  hard  rubber,  is  passed  into  the  bladder.  If 
desired,  one  electrode  may  be  inserted  into  the  rectum  instead  of  the 
bladder.  The  results,  although  transitoiy,  at  times  confer  consider- 
able relief. 

4.    ATONY   OF   THE   BLADDER. 

Atony  of  the  bladder  is  a  condition  which,  although  it  seems  very 
much  like  paralysis,  is  in  reality  altogether  different,  being  due  to 
partial  or  complete  loss  of  contractility  of  the  vesical  musculature. 


NEUROSES    OF    THE    BLADDER.  299 

In  paralysis  of  the  bladder  the  inability  to  urinate  depends  upon 
disease  of  the  motor  nerve-tracks,  in  atony  it  is  due  to  degeneration 
of  the  vesical  musculature,  the  nervous  mechanism  not  being  affected. 

It  cannot  be  denied  that  the  term  atony  of  the  bladder  does  not 
rightly  express  the  condition  above  explained,  and  it  would  be  better 
to  speak  of  partial  or  complete  degeneration  of  the  muscles  of  the 
bladder;  the  name  atony,  however,  has  been  adopted,  the  French 
school  especially  having  used  it  to  designate  weakness  of  the  bladder 
depending  upon  disease  of  the  musculature  in  contradistinction  to 
paralysis  and  paresis  due  to  faulty  innervation. 

This  impairment  of  the  musculature  most  frequently  is  due  to 
arteriosclerosis.  Just  as  arteriosclerosis  of  the  blood-vessels  of  the 
heart  weakens  the  cardiac  muscle,  so  likewise  does  arteriosclerosis 
of  the  blood-vessels  of  the  bladder  impair  the  vesical  musculature, 
causing  it  to  lose  its  power  of  contractility. 

Another  cause  of  this  defect  is  persistent  acute  retention  of  urine 
producing  overdistention  of  the  musculature,  as  a  result  of  which  its 
power  of  contractility  is  more  or  less  impaired.  It  thus  comes  to  pass 
that  after  several  of  these  attacks  the  patient  can  no  longer  empty 
his  bladder.  This  condition  is  very  common  among  prostatics.  It 
is,  of  course,  not  caused  by  the  prostate  suddenly  assuming  such  dimen- 
sions as  to  form  a  permanent  mechanical  obstruction  to  the  outflow 
of  urine,  but  rather  to  the  fact  that  engorgement  of  the  gland  originally 
gave  rise  to  retention  of  urine.  After  the  acute  exacerbations  subside 
and  the  patient  is  still  unable  to  void  his  urine,  the  circumstance  is 
to  be  attributed  to  injury  inflicted  upon  the  vesical  musculature  by 
over-distent  ion  of  the  bladder. 

I  have  also  frequently  observed  atrophy  of  the  musculature  of  the 
bladder  for  which  there  was  no  recognizable  cause.  It  is  interesting 
to  note  that  in  one  of  these  cases  there  was  also  atrophy  of  the  prostate. 
This  atrophy  manifested  itself  clinically  by  the  occurrence  of  residual 
urine  for  which  no  other  cause  could  be  found. 

Finally,  severe  parenchymatous  cystitis,  in  which  the  inflammatory 
process  extends  through  the  entire  thickness  of  the  vesical  wall,  may 
result  in  this  condition.  Fortunately  the  inflammation  generally 
confines  itself  to  the  mucous  membrane  and  the  subcutaneous  fatty 
and  connective  tissue,  but  occasionally  it  involves  the  muscle  and 
leads  to  sclerosis. 

Treatment  consists  in  the  application  of  those  measures  which  were 


300  DISEASES    OF    THE    URINARY    BLADDER. 

recommended  for  paralysis  of  the  bladder.  If  possible  the  cause 
should  be  removed.  Then  strychnine  internally,  aseptic  catheteriza- 
tion, irrigation  of  the  bladder  with  silver  nitrate  solution,  cold  douches 
over  the  bladder,  and  electricity  are  to  be  considered.  As  the  entire 
musculature  is  not  often  destroyed  it  frequently  happens  that  the 
unimpaired  portion  can  be  strengthened  by  these  means. 

ENURESIS. 

Enuresis,  which  may  be  either  nocturnal  or  diurnal,  deserves  special 
consideration  because  of  its  frequency.  As  is  well-known,  this  disease 
occurs  almost  exclusively  among  childern;  it  is  rarely  met  with  in  adults. 
It  occurs  most  frequently  in  children  under  eight  years  of  age. 

It  is  characteristic  of  this  disease  for  the  child,  generally  during 
sleep,  to  suddenly  empty  its  bladder.  Not  a  few  drops  are  expelled, 
but  the  entire  quantity  of  urine  in  the  bladder  is  voided.  Sometimes 
the  child  awakes,  but  at  other  times  sleep  is  not  interrupted  and  he 
does  not  know  that  he  has  wet  the  bed.  The  expulsion  of  urine  does 
not  occur  only  after  the  bladder  has  become  full,  but  often  takes  place 
during  the  first  hours  of  sleep,  before  much  urine  has  collected.  Some 
children  urinate  several  times  during  the  same  night.  During  the 
day  micturition  may  be  entirely  normal,  although  many  children  are 
obliged  to  satisfy  a  peremptory  demand  to  make  water  or  the  urine 
will  escape  in  their  clothing. 

The  explanation  of  this  malady  is  by  no  means  easy.  By  some  it 
is  thought  to  be  due  to  partial  paralysis  of  the  sphincter,  by  others  to 
spasm  of  the  detrusor;  others  again  believe  that  it  is  caused  by  faulty 
development  of  the  sphincter. 

If  the  disease  be  considered  from  a  practical  standpoint,  from  the 
cases  which  we  meet  with  in  every-day  practice,  the  theory  of  faulty 
development  of  the  vesical  sphincter  must  be  relinquished.  I  have 
seen  children  affected  with  enuresis  who  were  splendidly  developed  in 
every  respect.  I  also  believe  that  the  theory  of  paralysis  of  the  sphincter 
is  untenable,  for  were  the  disease  due  to  this  condition  the  entire  quan- 
tity of  urine  would  not  be  voided  at  once,  but  the  urine  would  trickle 
away  slowly,  and  some  would  be  found  in  the  bladder  after  the  bed 
had  been  wet. 

I  am  of  the  opinion  that  enuresis  is  caused  by  spasmodic  contraction 
of  the  detrusor  muscle  powerful  enough  to  overcome  the  resistance 
of  the  sphincter.     This  disparity  of  innervation  between  the  two  sets 


ENURESIS.  30I 

of  vesical  muscles,  which  is  normal  in  infancy,  persists  during  child- 
hood, and  constitutes  an  abnormal  condition.  While  normally  the 
contractions  of  the  detrusor  are  held  in  check  by  the  tonicity  of  the 
sphincter,  in  enuresis  the  conditions  are  reversed. 

Upon  what  this  disparity  of  innervation  depends  can  frequently 
not  be  determined.  Many  cases  occur  in  sensitive,  irritable  children, 
the  so-called  nervous  children,  if  one  cares  to  employ  the  expression. 
Rickets,  chlorosis,  and  terror  may  act  as  predisposing  causes.  Exposure 
to  wet  and  cold,  fissure  of  the  anus,  worms,  phimosis,  balanitis,  a 
very  narrow  meatus,  and  chronic  constipation  at  times  supply  the 
cause  for  the  abnormal  irritability  of  the  detrusor,  which  expresses 
itself  in  these  involuntary  contractions.  Ill-breeding  may  now  and 
then  be  responsible  for  the  condition. 

The  prognosis  is  good,  the  disease  either  being  overcome  by  treat- 
ment or  undergoing  spontaneous  cure  at  puberty. 
1  Treatment  is  very  satisfactory.  It  is  important  above  all  else  to 
ascertain  the  cause  of  the  trouble.  It  is  self-evident  that  the  local 
abnormalities  above  mentioned  which  excite  the  reflexes  of  the  detrusor 
must  be  overcome.  A  narrow  meatus  must  be  cut,  a  phimosed  prepuce 
must  be  split  open,  balanitis  must  be  cured.  For  rachitic  and  chlorotic 
children  tonic  treatment  is  indicated .     The  digestion  must  be  regulated. 

The  diet  must  also  be  regulated.  All  stimulating  foods,  as  well 
as  those  which  produce  flatulence,  are  to  be  avoided.  The  child 
should  not  be  allowed  to  drink  anything  for  an  hour  before  retiring, 
and  should  be  awakened  once  during  the  night  and  made  to  urinate. 
He  should  sleep  upon  a  hard  mattress  and  be  only  lightly  covered. 
Sleeping  upon  feather  beds  is  not  permissible.  Gymnastics,  exercise 
in  the  open  air,  and  the  avoidance  of  mental  overwork  are  indicated. 

Of  internal  remedies  belladonna,  which  is  known  empirically  to 
diminish  irritability  of  the  bladder,  accomplishes  the  most  good.  I 
have  seen  little  good  result  from  the  use  of  other  drugs  which  have 
been  recommended. 

[If  the  urine  shows  hyperacidity  a  mild  alkali  should  be  given.  I 
have  obtained  good  results  with  this  treatment,  and  am  led  to  believe 
that  some  cases  depend  upon  vesical  irritablity  caused  by  abnormal 
acidity  of  the  urine.] 

It  is  well  to  elevate  the  foot  of  the  bed  so  that  the  child  may  lie  in 
a  slanting  position  with  the  head  downwards.  By  this  means  the 
urine  will  be  forced  away  from  the  sphincter.     It  is  not  entirely  clear 


3<D2  DISEASES    OF    THE    URINARY    BLADDER. 

how  this  position  exerts  a  favorable  action,  and  the  matter  is  not  worth 
discussing.     Of  its  value,  however,  I  am  convinced. 

Faradization  of  the  bladder  from  three  to  five  times  weekly  is  of 
considerable  value.  One  electrode  is  placed  over  the  bladder  above 
the  symphysis  and  the  other  is  introduced  into  the  rectum;  as  strong  a 
current  as  can  be  well  endured  is  turned  on,  and  then  its  strength 
increased  at  short  intervals  for  a  few  seconds,  so  that  a  strong  electric 
shock  is  imparted.  The  slight  transitory  pain  produced  is  more  than 
counterbalanced  by  the  good  results  which  this  method  effectuates. 

In  cases  in  which  all  these  measures  fail  dilatation  of  the  urethra 
with  as  large  instruments  as  the  urethra  will  admit,  and  later  with 
Oberlander's  dilators,  may  be  tried. 


ANATOMY    AND    PHYSIOLOGY.  303 


DISEASES  OF  THE  PROSTATE  GLAND. 
ANATOMY  AND  PHYSIOLOGY. 

The  prostate  gland  lies  between  the  symphysis  pubis  and  the  rectum, 
or,  according  to  Kohlrausch,  between  two  lines  drawn  from  the  tip 
of  the  coccyx  to  the  upper  and  lower  margins  of  the  symphysis  pubis, 
respectively.  The  upper  and  longer  line  touches  the  base  of  the  gland, 
while  the  lower  and  shorter  one  strikes  the  apex.  Thus  it  is  seen  that 
the  base  is  above  and  the  apex  below. 

The  anterior  surface,  or  fades  pubica  as  it  is  sometimes  called,  is 
attached  to  the  pubic  arch  by  the  pubo-prostatic  ligament,  the  fibers  of 
which  are  interwoven  with  numerous  veins  (plexus  of  Santorini);  the 
posterior  surface,  or  fades  rectalis,  is  connected  with  the  rectum  by 
dense,  non-fatty  connective  tissue  in  which  there  are  no  large  vessels. 
The  lateral  surfaces  are  convex  in  shape  and  are  covered  by  the 
anterior  portion  of  the  levator  ani  muscle. 

The  prostate,  therefore,  lies  outside  the  pelvic  fascia, — not  within  the 
pelvis,  but  in  the  layer  of  tissue  which  forms  the  pelvic  floor;  namely, 
the  uro-genital  diaphragm. 

Strong  bands  of  fibro-muscular  tissue  are  found  between  the 
glandular  portions,  being  continuous  on  the  one  side  with  the  liga- 
mentous fibers  attached  to  the  pubic  arch  and  on  the  other  side  with 
the  musculature  of  the  bladder. 

The  urethra  perforates  the  gland  in  such  a  manner  as  to  make  the 
larger  segment  lie  below  and  the  smaller  one  above. 

In  shape  the  prostate  resembles  a  chestnut.  It  has  an  average  weight 
of  15  to  20  grm.  (3!  to  5  drachms.)  Its  greatest  transverse  diameter 
near  its  base  is  about  44  mm.  (2  inches),  its  longest  diameter  from  base 
to  apex  34  mm.  (1^-  inches)  and  its  greatest  thickness  about  15  mm. 
(|  of  an  inch). 

The  prostate  is  composed  of  a  fibro-muscular  and  a  glandular 
portion,  the  connective  tissue  and  muscular  fibers  forming  a  net-work 
between  the  meshes  of  which  the  glandular  substance  is  contained. 
The  fibrous  portion  of  the  net-work  extends  toward  the  periphery 
of  the  gland  and  becomes  lost-in  its  capsule;  the  muscle  fibers  are  more 
abundant  near  the  bladder,  where  they  have  a  circular  arrangement, 


3°4 


DISEASES    OF    THE    PROSTATE    GLAND. 


being  continuous  with  the  musculature  of  the  bladder.  This  aggrega- 
tion of  circular  fibers,  belonging  partly  to  the  prostate  and  partly  to 
the  bladder,  has  been  named  the  internal  sphincter  of  the  bladder. 
The  ends  of  the  muscle  fibers  are  continuous  with  the  compressor  of 
the  membranous  urethra,  and  with  it  form  the  so-called  external 
sphincter  of  the  bladder. 

The  glandular  elements  are  not  developed  until  puberty;  they 
reach  the  height  of  their  development  during  manhood,  while  in  old 
age  they  atrophy  and  are  replaced  by  connective  tissue.  The  glandular 
substance  is  not  evenly   distributed  throughout  the  organ;  toward 


Fig.  176. — The  periprostatic  plexus.     (Segond.) 

the  urethra  there  is  a  stronger  development  of  muscle,  while  toward 
the  rectum  the  glandular  substance  is  more  abundant. 

The  ducts  of  these  glands  unite  to  form  larger  ducts  which  have 
their  outlet  on  either  side  of  the  verumontanum. 

The  fine  blood-vessels  which  accompany  the  connective  tissue 
septa  are  derived  from  the  vesico-prostatic  branch  of  the  inferior  vesical 
artery.  The  veins  empty  into  the  dorsal  vein  of  the  penis  and  the 
veins  of  the  urethra.  They  form  a  plexus  around  the  glands,  the 
so-called  periprostatic  plexus,  which  may  normally  assume  large 
dimensions  (Fig.  176).  The  nerves  come  from  the  inferior  prostatic 
plexus. 

The  prostatic  secretion  is  a  grayish- white  fluid  resembling  milk 
and  having  an  alkaline  reaction.  When  seen  under  the  microscope 
it  looks  like  an  emulsion.     Numerous  small  drops  of  various  size, 


ABSENCE,    ATROPHY,    AND    CYSTS    OF    THE    PROSTATE.  305 

with  epithelial  cells  lying  between  them,  and  a  few  lymphocytes  or 
leucocytes  scattered  here  and  there  are  seen.  Very  seldom  the  strati- 
fied prostatic  bodies,  or  corpora  amylacea  are  met  with;  they  are  com- 
posed of  concentric  layers  and  contain  granular  substance  in  their 
interior. 

It  is  supposed  that  the  prostatic  secretion  maintains  the  vitality 
of  the  spermatozoa,  and  also  vivifies  those  which  have  lost  their  vitality. 
If  it  is  absent  from  the  semen  the  fertilizing  power  of  the  spermatozoa 
is,  according  to  Fiirbringer,  destroyed. 

ABSENCE,  ATROPHY,  AND  CYSTS  OF  THE  PROSTATE. 

Complete  absence  of  the  prostate  is  rare,  occurring  only  when  there 
are  other  defects  of  development  in  the  urinary  or  generative  organs. 

In  persons  in  whom  both  testicles  were  absent,  and  in  cryptorchids, 
there  has  been  complete  absence  of  the  prostate.  Partial  absence  of 
the  prostate  is  even  rarer;  a  remarkable  case  in  which  the  right  half 
of  the  gland,  together  with  the  right  colliculus  seminalis,  was  absent 
in  an  otherwise  well-developed  infant  has  been  reported  by  Beraud. 

Luschka  has  reported  an  instance  in  which  a  portion  of  the  gland 
was  separated  from  the  rest.  In  this  interesting  case  a  gland  exactly 
like  the  prostate  was  found  on  the  dorsum  of  the  penis  2  cm.  in  front 
of  the  line  of  union  of  the  corpora  cavernosa  This  was  supposed 
to  be  a  misplaced  middle  lobe  of  the  prostate. 

Atrophy  of  the  prostate  is  an  affection  which  has  been  especially 
studied  by  Englisch.  Occasionally  an  atrophied  prostate  is  met 
with  as  a  congenital  malformation.  Of  greater  interest  are  those 
forms  which  are  associated  with  destruction  of  the  testicles.  If 
atrophy  of  the  testicles  occurs  before  puberty  the  prostate  does  not 
develop;  if  it  occurs  after  puberty  an  atrophy  of  the  gland  begins, 
which,  according  to  my  observations,  affects  only  the  glandular 
substance,   the  connective  tissue  remaining  intact. 

In  wasting  diseases  the  prostate  may  imdergo  atrophy  the  same  as 
other  organs    (Thompson). 

Long-continued  pressure  upon  the  prostate  gives  rise  to  the  so- 
called  compression  atrophy.  With  the  exception  of  the  rare  cases 
in  which  tumors  of  adjacent  organs  compress  the  prostate,  the  usual 
cause  is  a  tight  stricture  of  the  urethra,  as  a  result  of  which  the  urine 
becomes  dammed  up  behind  the  stricture  and  exerts  continous  pressure 


306  DISEASES    OF    THE    PROSTATE    GLAND. 

upon  the  prostate".  It  is  for  this  reason  that  prostatic  hypertrophy 
so  seldom  occurs   in   men  having  pronounced   stricture. 

Finally,  in  old  age  the  prostate  as  well  as  other  organs  may  atrophy 
under  the  influence  of  sclerosis,  all  the  tissues,  fibrous,  muscular, 
and  glandular,  being  affected. 

As  a  result  of  weakness  of  the  musculature  of  the  gland,  a  portion 
of  which  is  really  identical  with  the  musculature  of  the  bladder,  incon- 
tinence of  urine  gradually  develops,  at  first  manifesting  itself  only  at 
night,  but  later  persisting  through  the  day  as  well.  In  contradis- 
tinction to  the  condition  which  obtains  in  prostatic  hypertrophy  there 
is  no  over-distention  of  the  bladder,  and  consequently  the  dribbling 
of  urine  which  occurs  is  not  the  incontinence  of  retention.  There  is, 
moreover,  no  residual  urine  in  atrophy  of  the  gland. 

In  very  exceptional  cases  of  atrophy,  however,  retention  of  urine 
may  occur  as  the  result  of  irregularities  or  folds  in  the  relaxed  sphincter, 
so  that  the  clinical  picture  resembles  that  of  prostatic  hypertrophy. 
Differential  diagnosis  can  be  made  by  rectal  examination,  which  will 
reveal  the  condition  of  the  prostate. 

The  urgency  of  urination  ordinarily  present  in  atrophy  of  the  gland 
is  to  be  attributed  to  the  pressure  exerted  by  the  process  of  contraction 
which  is  going  on. 

The  defective  tonicity  of  the  sphincter  favors  the  entrance  of  bacteria 
into  the  bladder,  so  that  cystitis  seldom  fails  to  develop. 

Impairment  of  sexual  power  is  partly  due  to  the  age  of  the  patients, 
but  may  perhaps  also  be  furthered  by  the  associated  atrophy  of  the 
testicles. 

The  symptoms  just  described,  together  with  rectal  examination 
and  the  use  of  the  sound,  enable  one  to  make  a  correct  diagnosis. 
The  urethra  is  shortened  instead  of  being  lengthened,  as  it  is  in  pros- 
tatic hypertrophy,  and  the  resistance  encountered  in  the  prostatic 
urethra  in  the  latter  affection  is  absent. 

Treatment  is  not  at  all  promising.  The  use  of  large  metal  sounds, 
and  also  faradization  with  one  electrode  at  the  sphincter  of  the  bladder 
and  the  other  in  the  rectum,  is  worthy  of  trial.  Cases  in  which 
retention  occurs  must  be  treated  by  regular  aseptic  catheterization. 

Cysts  of  the  prostate  are  exceedingly  rare.  The  little  that  we 
know  about  them  we  owe  to  the  researches  of  Englisch. 

There  are  small  retention  cysts  of  the  sinus  pocularis  due  to  occlu- 
sion of  its  orifice.     They  are  of  special  importance  because  it  is  very 


INJURIES  OF  THE  PROSTATE.  307 

probable  that  retention  of  urine  occurring  in  the  new-born  is  due  to 
their  presence.  When  the  child  is  catheterized  it  is  probable  that 
the  cyst  is  ruptured,  as  he  generally  is  able  to  empty  his  bladder  after- 
wards. Englisch  states  that  this  occlusion  of  the  orifice  of  the  sinus 
pocularis  finds  its  analogue  in  the  coalescence  of  the  layers  of  the 
prepuce  or  its  adhesion  to  the  glans,  a  condition  which  is  very  fre- 
quently seen. 

Other  cysts  are  supposed  to  be  formed  from  embryonic  remnants. 
At  first  they  are  small,  but  if  they  persist  they  become  large,  and  it 
is  likely  that  the  few  large  cysts  of  the  prostate  which  have  been  observed 
resulted  from  the  growth  of  these  small  congenital  anomalies. 

These  cysts  must,  of  course,  be  distinguished  from  cyst-like  for- 
mations such  as  hydrops  of  the  seminal  vesicles  and  echinococcus 
and  dermoid  cysts,  which  are  different  both  in  origin  and  nature. 
Solid  tumors  of  the  prostate,  and  diverticulum  of  the  bladder,  as  well 
as  an  overdistended  bladder  may  be  confounded  with  these  cysts. 

Differential  diagnosis  can  be  made  by  emptying  the  bladder  with 
the  catheter  and  simultaneously  pressing  upon  the  viscus  both  above 
the  symphysis  and  through  the  rectum,  and  finally  by  exploratory 
puncture  through  the  rectum.  A  diverticulum  and  a  distended  blad- 
der, which  when  felt  through  the  rectum  give  the  impression  of  being 
cysts,  disappear  after  catheterization  and  compression  of  the  bladder, 
while  cysts  of  the  prostate  are  uninfluenced  by  these  measures.  Pros- 
tatic tumors  when  palpated  through  the  rectum  over  a  sound  passed 
into  the  bladder  feel  different  than  cysts.  Exploratory  puncture 
with  a  capillary  trocar,  although  it  is  not  dangerous  even  should  the 
bladder  be  punctured,  should  be  undertaken  only  in  cases  of  exigency. 

As  to  treatment,  single  or  repeated  puncture  will  often  suffice, 
but  in  some  cases  the  cyst  has  to  be  incised. 

INJURIES  OF  THE  PROSTATE. 

Injuries  resulting  from  catheterization  will  not  be  considered  under 
this  heading  as  they  have  been  discussed  under  false  passages  (see 
also  under  hypertrophy  of  the  prostate).  Injuries  of  the  prostate 
caused  by  gunshot  or  stab  wounds,  by  falls  in  which  the  perineum 
strikes  against  an  angular  object,  by  splinters  of  bone  from  a  fractured 
pelvis,  and  by  pointed  foreign  bodies  introduced  into  the  rectum 
are  the  ones  which  will  here  occupy  our  attention. 

The  symptoms  of  injury  of  the  prostate  vary  according  as  the  urethra 


308  diseases  of  the  prostate  gland. 

is  or  is  not  wounded.  When  the  urethra  is  involved,  even  though 
the  wound  be  slight,  severe  haemorrhage  results,  and  owing  to  the 
close  proximity  of  the  injured  part  to  the  rectum  infection  readily 
occurs  and  leads  to  the  formation  of  periprostatic  abscess.  Both 
blood  and  urine  are  seen  to  ooze  from  the  wound.  This  symptom, 
however,  is  not  constant,  for  the  blood  may  flow  back  into  the  bladder, 
and,  moreover,  the  wound  may  be  so  small  as  not  to  permit  the 
visible  outflow  of  urine.  A  careful  examination  with  the  finger  and 
the  sound,  together  with  rectal  palpation,  will  reveal  the  true  state 
of  affairs. 

These  injuries  are  dangerous  when  the  periprostatic  plexus  is 
wounded.  The  resulting  haemorrhage  may  be  most  difficult  to  control. 
Urinary  infiltration  and  phlegmon,  as  well  as  inflammation  of  the 
neighboring  parts,  are  liable  to  occur. 

When  the  urethra  is  not  involved  in  the  injur}7  treatment  may  be 
confined  to  the  arrest  of  haemorrhage.  In  case  the  urethra  is  wounded 
a  retention-catheter  must  be  introduced  to  prevent  the  urine  from 
contaminating  the  wound,  and  the  wound  then  treated  in  accordance 
with  the  usual  rules  of  surgery. 

INFLAMMATION  OF  THE  PROSTATE. 

Inflammation  of  the  prostate  seldom  occurs  as  an  idiopathic  affection, 
but  usually  follows  inflammation  in  the  urethra,  especially  gonorrhoea, 
although  simple  inflammation  associated  with  vesical  catarrh  or 
stricture  of  the  urethra,  or  resulting  from  frequent  or  permanent 
catheterization,  may  extend  to  the  prostatic  ducts  and  cause  pros- 
tatitis. A  single  catheterization,  a  stone- crushing  operation,  forced 
injections,  vesical  calculi,  in  short  any  injury  in  wThich  infection  may 
take  place  is  likely  to  be  followed  by  the  same  results.  It  is  to  be 
remembered  that  the  urethra  is  the  habitat  of  bacteria  which  may 
become  virulent  when  injury  is  inflicted. 

Excesses  in  venery,  and  especially  frequently  repeated  mastur- 
bation, as  well  as  external  injury  such  as  severe  jarring  caused  by 
bicycling  or  riding,  may  produce  congestion  of  the  urethra  and  prostate; 
as  a  result  of  the  action  of  urethral  microorganisms  this  condition 
is  converted  into  one  of  inflammation. 

In  comparison  with  prostatitis  due  to  extension  of  a  catarrhal  or 
suppurative  process  in  the  urethra  this  form  is  very  rare.  It  is  also 
rare  for  the  prostate  to  become  inflamed  as  the  result  of  extension  of 


ACUTE   PROSTATITIS.  309 

disease  from  neighboring  organs,  as  for  example,  from  the  rectum 
or  its  surrounding  tissues. 

Finally,  it  must  be  borne  in  mind  that  suppuration  in  the  prostate 
may  occur  in  certain  constitutional  diseases,  such  as  pyaemia,  typhus 
fever,  parotitis,  angina,  pneumonia,  etc. 

Inflammation  of  the  prostate  may  be  either  acute  or  chronic. 

ACUTE  PROSTATITIS. 

With  the  exception  of  metastases  and  the  exceptional  cases  in  which 
acute  prostatitis  follows  injury  of  the  urethra,  the  disease  is  caused 
exclusively  by  gonorrhoea,  or  to  use  a  more  general  term,  by  urethral 
catarrh.  In  every  case  of  gonorrhoea,  and  in  any  and  every  stage  of 
the  disease,  this  complication  may  develop. 

There  are  different  forms  of  acute  prostatitis  depending  upon  the 
extent  and  intensity  of  the  inflammation. 

The  mildest  form  is  catarrhal  prostatitis. 

Ghon,  Schlagenhaufer,  and  Finger  have  shown  how  quickly  the 
gonococci  penetrate  the  epithelium  of  Littre's  glands  and  Morgagni's 
crypts.  They  enter  the  orifice  of  the  prostatic  ducts  with  equal 
facility  and  produce  suppuration  and  exfoliation  of  the  epithelium 
the  same  as  upon  the  surface  of  the  urethra.  The  inflammatory 
process  remains  localized  in  the  ducts,  or  in  the  glands  immediately 
surrounding  the  caput  gallinaginis. 

The  disturbance  caused  by  this,  the  lightest  form  of  the  disease, 
is  relatively  mild.  The  symptoms  of  posterior  urethritis  predominate. 
Strangury  and  painful  micturition  are  ordinarily  of  moderate  degree. 
If  the  urine  is  voided  in  three  portions  all  three  will  be  found  slightly 
turbid  or  flocculent.  In  the  last  glass  comma-shaped  bodies  will 
frequently  be  seen ;  they  are  composed  of  masses  of  pus-cells  which 
are  expelled  from  the  prostatic  ducts.  Gonococci  are  often  found  in 
them.  The  general  health  is  little  disturbed.  Rectal  examination 
reveals  no  changes  in  the  prostate  for  the  reason  that  the  substance 
of  the  gland  is  not  affected.  Even  though  the  posterior  urethritis 
is  cured  the  prostatic  inflammation  usually  persists  and  becomes 
chronic. 

From  this  affection  the  so-called  follicular  prostatitis  differs 
little  except  in  intensity,  the  causes  of  both  forms  and  their  manner  of 
development  being  the  same.  The  prostatic  ducts  and  the  super- 
ficial glandular  structures  become  engorged  with  pus,  or  their  orifice 


310  DISEASES    OF    THE    PROSTATE    GLAND. 

even  occluded,  so  that  small  abscesses  are  formed,  which  are  known 
as  follicular,  or  pseudo-abscesses,  because  they  develop  in  a  natural 
cavity. 

The  symptoms  in  this  form  of  the  disease  are  somewhat  more  severe 
than  in  the  catarrhal  form.  The  strangury  is  considerably  more 
severe,  and  the  pain  increases  during  micturition,  being  felt  especially 
at  the  end  of  the  act.  The  urine  is  flocculent  or  cloudy  and  the  pre- 
viously mentioned  comma-shaped  bodies  are  seldom  absent.  Rectal 
examination  rarely  reveals  any  abnormalities,  although  some  authors 
state  that  they  have  often  felt  indurated,  sensitive  nodules  the  size 
of  a  hemp-seed. 

The  general  health  is  not  materially  deranged.  The  patients 
suffer  from  urgency  of  urination  and  pain,  but  are  usually  free  from 
fever,  and  able  to  maintain  their  ordinary  activity. 

This  follicular  prostatitis  terminates  either  by  gradual  absorption 
of  the  purulent  exudate,  in  which  case  both  strangury  and  pain  subside 
and  the  urethritis  simultaneously  improves,  or  the  inflammation  pro- 
gresses, the  abscesses  coalesce,  and  the  deeper  parts  of  the  prostate 
become  involved.  The  condition  which  then  obtains  is  known  as 
parenchymatous  prostatitis.  In  this  form  either  the  entire  gland, 
or  at  least  portions  of  it  remote  from  the  urethra,  is  affected.  The 
extension  of  the  process  first  shows  itself  by  a  serous  infiltration  of 
the  entire  organ,  a  condition  of  congestion,  as  the  result  of  which  the 
gland  becomes  swollen  and  cedematous.  The  enlargement  is  readily 
detected  by  palpation  through  the  rectum;  the  swelling  may  be  either 
unilateral  or  bilateral.  Pain  upon  pressure  is  not  very  severe.  The 
patient  experiences  a  sense  of  pressure  in  the  perineum  and  at  the 
anus,  as  though  there  were  a  foreign  body  in  the  rectum.  Micturition 
is  slightly  painful  and  the  stream  somewhat  impeded.  The  general 
health  begins  to  suffer,  but  fever  may  be  entirely  absent. 

If  the  serous  infiltration  and  engorgement  subside  the  symptoms 
improve  and  the  patient  may  entirely  recover.  Usually,  however, 
the  morbid  process  advances,  small- celled  infiltration  occurs  in  and 
around  the  glands,  and  small  follicular  abscesses,  the  same  as  those 
already  mentioned,  develop  and  become  confluent  owing  to  destruction 
of  the  connective  tissue  stroma. 

Simultaneously  with  the  advance  of  this  morbid  process  the  symp- 
toms become  intensified.  High  fever  may  be  present,  but  again  the 
patient  may  be  entirely  free  from  fever.     The  general  health,  however, 


ACUTE    PROSTATITIS.  311 

is  always  impaired;  the  appetite  is  poor,  the  tongue  dry,  dysuria  and 
pain  upon  urination  increase  in  severity,  and  there  is  an  unbear- 
able feeling  of  heaviness  and  fullness  in  the  perineum  and  rectum, 
which  may  become  so  severe  as  to  amount  to  sharp  pain.  Defecation 
causes  great  pain,  and  palpation  of  the  prostate  through  the  rectum 
gives  rise  to  most  exquisite  suffering.  Even  the  passage  of  the  finger 
through  the  sphincter  is  excessively  painful.  The  gland  is  hard  and 
swollen,  the  enlargement  occurring  in  whichever  direction  the  inflam- 
matory process  extends. 

If  resolution  occurs,  which  is  not  uncommon,  the  symptoms  gradually 
become  less  and  less  intense;  micturition  becomes  free  and  less  painful, 
evacuation  of  the  bowels  less  difficult,  the  appetite  returns,  and  the 
general  health  improves. 

In  other  cases  the  destructive  process  of  suppuration  advances 
and  prostatic  abscess  is  the  result.  The  disease  is  then  manifested 
by  the  most  severe  symptoms.  The  patient  presents  the  appearance 
of  being  desperately  ill,  being  completely  prostrated  and  unable  to 
take  nourishment.  The  tongue  is  dry  and  coated  and  micturition 
is  difficult  or  impossible.  Complete  retention  of  urine  necessitates 
regular  catheterization,  which  increases  the  discomfort  felt  in  the 
perineum  and  rectum.  The  bowels  will  not  move  without  the  use 
of  purgatives  or  enemata,  and  when  a  passage  is  secured  it  is  attended 
with  great  pain.  Palpation  through  the  rectum  reveals  the  presence 
of  a  fluctuating  mass.  This  latter  condition,  however,  does  not 
invariably  exist,  for  it  may  happen  that  the  suppuration  does  not 
extend  in  the  direction  of  the  rectum.  Thus  it  may  be,  especially 
in  those  cases  which  come  under  observation  early,  that  the  prostate 
is  felt  as  an  indurated,  enlarged  body.  Pus  may  be  present  in  the 
interior  of  the  gland,  but  there  is  no  fluctuation. 

In  such  cases  the  surgeon  must  endeavor  to  determine  from  the 
clinical  picture  whether  suppuration  is  or  is  not  present.  It  is  impor- 
tant to  remember  that  fever  is  not  an  intrinsic  part  of  the  symptom- 
complex.  I  have  seen  more  prostatic  abscesses  run  their  course 
without  fever  than  I  have  seen  accompanied  by  it.  Puncture  through 
the  rectum  is  permissible  as  a  diagnostic  measure.  It  is  performed 
by  plunging  a  guarded  capillary  trocar  into  the  portion  of  the  prostate 
in  which  pus  is  suspected.  A  finger  in  the  rectum  guides  the  point 
of  the  instrument  and  prevents  it  from  penetrating  a  pulsating  spot. 
I  have  never  seen  any  harm  follow  such  puncture.     Very  often  doubtful 


312  DISEASES    OF    THE    PROSTATE    GLAND. 

cases  have  been  cleared  up  by  obtaining  pus  with  a  syringe  attached 
to  the  end  of  the  trocar. 

If  the  process  be  left  to  itself  it  usually  progresses  until  it  results 
in  complete  destruction  of  the  gland,  which  becomes  converted  into 
a  large  suppurating  cavity.  Fortunately,  however,  rupture  generally 
occurs  before  this  extreme  condition  is  reached.  The  abscess  most 
frequently  breaks  into  the  urethra,  rupture  either  taking  place  spon- 
taneously or  resulting  from  catheterization  necessitated  by  retention 
of  urine.  Rupture  may  take  place  through  the  perineum  or  into 
the  rectum;  or  what  is  less  frequent,  the  abscess  may  break  into  the 
ischiorectal  fossa,  into  the  groin,  or  through  the  obturator  foramen 
Rupture  into  the  abdominal  cavity  is  an  occurrence  of  the  greatest  rarity. 

Rupture  is  usually  immediately  followed  by  relief.  Micturition 
and  defecation  become  easier,  pain  and  tenesmus  disappear,  and  the 
patient's  general  health  improves.  After  spontaneous  rupture,  however, 
it  is  not  uncommon  for  the  opening  to  become  closed  again,  and  for 
retention  to  recur  as  the  result  of  closure.  The  symptoms  then  return 
but  they  usually  are  less  severe  than  during  the  primary  period  of 
suppuration,  inasmuch  as  fresh  rupture  generally  occurs  from  time  to 
time.  The  final  result  of  these  spontaneous  ruptures  is  chronic  pros- 
tatitis. 

If  the  first  rupture  causes  a  sufficiently  large  opening  healing  may 
take  place.  The  abscess  cavity  becomes  smaller,  fills  with  granulation 
tissue,  and  a  scar  finally  forms  which  can  be  felt  as  a  depression  when 
the  gland  is  palpated  through  the  rectum. 

Sterility  may  follow  suppuration  of  the  prostate.  It  is  caused  in 
either  one  of  two  ways.  The  entire  gland  may  suppurate  so  that  its 
power  of  secretion  is  lost,  in  which  case,  provided  Furbringer's  theory 
that  the  prostatic  juice  maintains  the  vitality  of  the  spermatozoa  is 
correct,  the  semen  will  be  devoid  of  the  power  of  fecundation.  Accord- 
ing to  my  experience,  however,  sterility  is  not  often  produced  by 
suppuration,  enough  of  the  gland  evidently  being  preserved  to  main- 
tain the  vitality  of  the  spermatozoa.  A  large  number  of  my  patients 
who  had  prostatic  abscess  were  later  blessed  with  children. 

The  second  way  in  which  sterility  may  result  is  of  more  importance. 
It  may  come  to  pass  that  the  vas  deferens  may  be  so  constricted  by  the 
formation  of  scar-tissue  in  the  prostate  that  its  lumen  becomes  obliter- 
ated ;  the  vas  may  also  be  obliterated  by  extension  of  the  inflammatory 
process  to  its  interior. 


ACUTE    PROSTATITIS.  313 

Acute  prostatitis  may  run  a  very  dangerous  course  when  the  con- 
nective tissue  between  the  prostate  and  rectum  becomes  involved 
in  the  morbid  process.  A  periprostatic  phlegmon,  or  even  peri- 
prostatic phlebitis  with  thrombosis  of  the  periprostatic  venous 
plexus  and  consequent  pyaemia,  may  then  result. 

When  a  periprostatic  phlegmon  develops  the  symptoms  become 
much  worse.  High  fever  and  chills  are  always  present,  the  temper- 
ature rising  as  high  as  410  C.  [105. 8°  F.].  The  well-defined  outline  of 
the  prostate  can  no  longer  be  felt  through  the  rectum  as  is  the  case 
when  the  inflammation  remains  confined  to  the  gland  itself.  The 
contour  of  the  gland  is  lost.  The  infiltration  extends  upwards  and 
also  laterally  along  the  anterior  wall  of  the  true  pelvis.  The  wall  of 
the  rectum  is  no  longer  movable  over  the  prostate,  but  seems  adherent 
to  it.  The  termination  of  this  condition  cannot  be  foretold.  There 
is  danger  of  sepsis,  although  rupture  of  the  phlegmon  into  the  rectum 
is  a  more  frequent  termination.  Urethro-rectal  and  vesico-rectal 
fistulae  occasionally  result  from  this  rupture. 

The  very  uncommon  phlebitis  of  the  periprostatic  plexus  is  an  even 
more  serious  complication.  The  severest  constitutional  symptoms 
are  present,  the  patient  showing  the  typical  signs  of  violent  sepsis. 
In  one  such  case  Nogues  palpated  a  hard,  irregular  tumor  through 
the  rectum  which  felt  like  a  mass  of  thick  cords.  This  case  progressed 
to  cure;  as  a  rule,  however,  the  prognosis  is  very  bad. 

The  treatment  of  acute  prostatitis  varies  according  to  the  degree 
of  severity  of  the  disease. 

In  the  mild  forms,  that  is,  the  catarrhal,  the  follicular,  the  paren- 
chymatous, and  likewise  in  the  beginning  of  serous  infiltration,  or 
even  when  small  miliary  abscesses  have  formed,  antiphlogistic  measures 
are  to  be  employed.  Rest  in  bed,  light  diet,  regulation  of  the  bowels, 
discontinuation  of  all  local  treatment  of  the  gonorrhoea,  leeches  to 
the  perineum,  hot  sitz-baths,  and  hot-water  bags  to  the  perineum 
are  the  appropiate  measures.  The  application  of  heat  to  the  perineum 
causes  hyperemia  of  the  external  parts  and  thereby  relieves  congestion 
of  the  prostate.  I  do  not  favor  the  application  of  heat  to  the  rectum 
by  means  of  the  psychrophore. 

For  severe  pain  the  narcotics  are  indicated.  If  retention  of  urine 
occurs,  the  patient  must  be  regularly  catheterized,  and  his  bladder 
washed  out  with  silver  nitrate  solution  1 :  2000.  I  always  employ 
soft  instruments  (Nelaton's).     The  prostatic  urethra  is  usually  narrowed 


314  DISEASES    OF    THE    PROSTATE    GLAND. 

by  the  swollen  prostate,  so  that  a  metal  catheter  cannot  be  readily 
passed.  For  internal  administration  I  advise  small  doses  of  salicylic 
acid   (i.o  a  day).     This  treatment  usually  arrests  the  disease. 

If  suppuration  has  occurred  before  the  case  comes  under  observation, 
an  incision  must  be  made  at  once,  in  order  to  prevent  further  destruc- 
tion of  the  glandular  substance. 

In  general  it  may  be  stated  that  the  gland  should  be  incised  from 
the  nearest  point  to  the  focus  of  suppuration.  If  the  perineum  is 
swollen  the  incision  should  be  made  there;  if  the  suppurative  process 
has  extended  toward  the  rectum,  then  the  abscess  may  be  opened  by 
the  rectal  route,  after  the  mucous  membrane  of  the  rectum  has  been 
carefully  cleansed  and  the  bowel  above  packed  with  iodoform  gauze. 
The  abscess  may  also  be  opened  through  a  prerectal  incision;  the 
latter  procedure  has  the  advantages  that  it  can  be  performed  under 
strict  asepsis  and  that  the  rectum  is  not  involved  in  the  wound. 

By  whatever  method  the  abscess  is  opened  healing  will  take  place.. 
I  have  treated  innumerable  cases  of  prostatic  abscess  due  to  urethral 
infection  and  have  never  lost  a  case,  although  I  have  had  two  fatal 
cases  of  prostatic  suppuration  occurring  as  a  complication  of  pros- 
tatic hypertrophy.     Both  were  in  old  men. 

The  prognosis  of  abscess  of  the  prostate,  then,  is  good  in  young  persons, 
in  whom  it  follows  urethral  infection ;  in  old  men  affected  with  purulent 
vesical  catarrh  there  is  little  chance  of  cure. 

CHRONIC  PROSTATITIS. 

The  etiology  of  chronic  prostatitis  is  the  same  as  that  of  the  forms 
already  discussed,  for  all  the  causes  which  produce  acute  or  suppura- 
tive prostatitis  may  also  give  rise  to  the  chronic  form  of  the  disease 
if  the  injurious  influence  is  exerted  in  a  slower  and  less  violent  maimer. 
Thus  it  is  that  gonorrhoea,  stricture,  cystitis,  vesical  and  pros- 
tatic calculi,  hypertrophy  of  the  prostate,  injury  with  catheters  and 
sounds,  and  excess  in  venery  (onanism)  cause  chronic  inflammation 
of  the  prostate.  In  other  cases,  acute  prostatitis,  though  apparently 
cured,  gradually  passes  into  a  state  of  chronicity. 

The  frequency  of  chronic  prostatitis  is  very  great.  Although 
Furbringer  denies  this,  further  investigation  has  shown  that  it  is 
correct.  These  conflicting  views,  to  which  we  shall  again  refer,  are  due 
to  the  difference  of  opinion  as  to  what  constitutes  chronic  prostatitis. 

Considered  from  the  standpoint  of  morbid  anatomy  several  different 


CHRONIC    PROSTATITIS.  315 

conditions  may  be  included  under  the  term.  The  simplest  of  these 
is  a  desquamative,  or  desquamatory-suppurative,  inflammation  of  the 
prostatic  ducts.  This  is  merely  an  extension  of  the  urethral  inflamma- 
tion to  the  surface  of  the  ducts,  the  deeper  portions  being  uninvolved. 
It  is  a  superficial  catarrh  affecting  the  ducts  and  some  of  the  glandular 
structure  nearest  the  caput  gallinaginis.  The  acini  are  filled  with 
desquamated  squamous  epithelium  and  leucocytes;  there  are,  how- 
ever, no  changes  in  the  walls. 

Conditions  become  altered  if  the  inflammation  penetrates  deeper 
and  attacks  the  walls  of  the  acini  and  ducts.  A  glandular  and  peri- 
glandular infiltrate  is  then  poured  out,  leucocytes  and  epithelioid  cells 
permeating  the  parietes  of  the  acini  and  invading  the  surrounding 
tissue.  The  epithelium  lining  the  acini  shows  cloudy  swelling,  and  the 
nuclei  take  stains  poorly  or  not  at  all.  In  this  stage  of  small-celled 
infiltration  the  prostate  is  soft  and  saturated  with  serum,  and  upon 
section  is  found  to  be  of  a  dirty  brown  color.  The  walls  of  the  ducts 
are  thickened  and  their  orifices  distended. 

In  certain  portions  of  the  gland  it  will  be  found  that  the  formation 
of  connective  tissue  has  already  taken  place.  Part  of  the  glandular 
substance  is  completely  destroyed,  the  prostatic  ducts  are  dilated, 
and  small  cavities  filled  with  turbid,  milky,  or  even  purulent  fluid 
are  observed.  The  connective  tissue  between  the  acini-  seems  more 
abundant  than  it  is  under  normal  conditions,  and  looks  like  broad 
bands  of  indurated  scar-tissue.  If  destruction  of  the  glandular  sub- 
stance progresses,  cavities  separated  from  one  another  by  bands  of 
scar-tissue  are  formed. 

In  accordance  with  these  anatomic  changes,  catarrhal,  sero-purulent, 
infiltrative,  parenchymatous  and  sclerotic  forms  of  chronic  prostatitis 
might  be  distinguished,  but  it  is  not  advisable  to  make  such  a  distinc- 
tion, for  the  reason  that  the  different  processes  cannot  be  discriminated 
clinically,  and  also  because  they  often  exist  simultaneously.  Certain 
portions  of  a  prostate  may  show  nothing  but  beginning  catharrhal 
inflammation;  in  other  parts  cysts  with  sclerotic  walls  are  observed, 
and  in  still  others  small-celled  and  serous  infiltration  are  perceptible. 

Symptoms  and  Diagnosis.  It  is  important  to  know  that  a  large 
number  of  cases  of  chronic  prostatitis  are  entirely  without  symptoms 
and  can  only  be  discovered  by  examination  of  the  prostatic  secretion. 

The  mild  form  in  which  only  the  ducts  and  neighboring  acini  are 
affected,  and  in  which  subjective  symptoms  as  well  as  abnormalities 


316  DISEASES    OF    THE    PROSTATE    GLAND. 

of  the  prostate  as  determined  by  rectal  palpation  are  wanting,  can 
rarely  be  diagnosticated.  It  is  only  in  the  case  of  patients  who  are 
examined  because  they  are  worried  by  the  persistence  of  filaments 
in  their  urine  after  the  subsidence  of  an  attack  of  gonorrhoea  that  this 
condition  is  discovered;  in  such  cases  it  will  be  found  to  exist  with 
very  great  frequency.  I  do  not  place  the  percentage  too  high  when 
I  state  that  it  is  present  in  85  per  cent  of  all  cases  of  chronic  posterior 
urethritis. 

It  can  be  recognized  only  by  massaging  the  prostate  after  the  urethra 
has  been  cleansed,  which  may  be  done  either  by  the  patient  allowing 
his  bladder  to  become  well  filled  and  then  forcibly  expelling  the  urine 
and  thereby  washing  away  all  the  secretion  from  the  urethra,  or  by 
irrigating  both  anterior  and  posterior  urethra  with  sterile  water  until 
the  fluid  comes  away  clear.  I  do  not  advise  the  latter  method  because 
it  causes  slight  trauma,  so  that  many  leucocytes  will  be  found  which 
otherwise  would  not  be  present.  It  is  better,  if  the  bladder  does  not 
contain  enough  urine,  to  inject  sterile  water  and  then  let  the  patient 
expel  it.  By  this  means  all  the  secretion  will  be  washed  away  and 
the  prostate  can  then  be  massaged. 

In  contradistinction  to  the  normal  prostatic  fluid,  which  shows 
only  epithelium,  lecithin -bodies,  with  here  and  there  a  lymphocyte 
and  occasionally  a  laminated  prostatic  body,  the  secretion  thus  pressed 
out  contains  red  blood-corpuscles  and  a  greater  or  less  number  of 
pus-cells,  which  are  either  free  or  lie  between  closely  adjacent  layers 
of  epithelium.  In  order  to  be  certain  that  these  pus-corpuscles 
come  from  the  prostate  the  urethra  must  have  been  previously  cleansed. 

The  presence  of  pus-cells  in  the  prostatic  fluid  is  often  the  only 
abnormality  which  can  be  detected.  As  this  method  of  examination 
is  practised  only  in  exceptional  cases,  it  is  readily  seen  why  Fiirb ringer 
is  of  the  opinion  that  prostatitis  is  a  comparatively  rare  complication 
of  gonorrhoea,  whereas  I  believe  it  to  be  present  in  almost  all  cases 
of  long-standing  urethral  catarrh. 

There  are  similar  cases  in  which  the  only  sign  of  disease  is  occasional 
cloudiness  of  the  urine.  This  cloudiness  is  caused  either  by  pus  or 
by  bacteria,  or  in  some  cases  by  both.  When  a  person  thus  affected 
is  placed  under  treatment  and  his  bladder  irrigated  with  silver  solution, 
his  condition  soon  improves;  the  urine  becomes  clear,  but  in  a  short 
time  the  turbidity  recurs.  If  the  pathogenesis  of  these  cases  be  sought, 
the  prostate  massaged  and  its  secretion  examined,  it  will  be  found 


CHRONIC   PROSTATITIS.  317 

that  the  secretion  contains  pus.  The  condition  will  then  be  plain. 
As  soon  as  the  bladder  is  disinfected  clear  urine  is  voided ;  when  treat- 
ment is  stopped,  however,  reinfection  takes  place  from  the  purulent 
and  germ-laden  secretion  of  the  prostate. 

Although  this  class  of  cases  constitute  the  majority,  yet  there  are 
others  in  which  subjective  symptoms  are  present,  and  in  which  other 
objective  symptoms  than  turbidity  of  the  urine  exist. 

The  subjective  symptoms  consist  in  slight  strangury,  painful  mictu- 
rition, especially  at  the  termination  of  the  act,  a  feeling  of  heaviness 
and  fullness,  together  with  a  sensation  of  itching  in  the  perineum  and 
rectum,  and  pain  upon  defecation.  Sexual  intercourse  and  pollutions 
are  also  painful.  In  addition  to  these  symptoms  many  nervous 
phenomena  occur,  but  they  undoubtedly  owe  their  existence  to  a 
concomitant  neurosis  rather  than  to  the  prostatitis.  The  patients 
believe  that  their  sexual  power  is  impaired;  cohabitation  is  difficult 
or  impossible,  ejaculation  occurring  too  soon,  or  at  times  taking  place 
even  before  intromission  can  be  effected.  Frequent  emissions,  pain  in 
the  back,  and  irritability  of  temper  are  constant  manifestations.  In 
general  it  may  be  stated  that  this  condition,  which  can  give  rise  to 
severe  hypochondria,  is  to  be  attributed  to  the  fact  that  the  patients 
believe  themselves  to  be  sicker  than  they  really  are.  No  material 
basis  for  their  symptoms  can  be  found,  and,  moreover,  the  readiness 
with  which  their  condition  improves  under  proper  treatment  shows 
that  their  trouble  is  largely  imaginary. 

The  idea  that  prostatorrhcea,  a  condition  in  which  the  prostatic 
fluid  is  discharged  during  defecation  or  micturition,  or  independently 
thereof,  is  a  sign  of  prostatitis,  must  be  relinquished.  The  two  have 
nothing  in  common.  There  are  many  cases  of  prostatorrhcea  in 
which  the  secretion  contains  no  pus,  and,  on  the  other  hand,  there 
are  many  cases  of  prostatitis  in  which  no  signs  of  prostatorrhcea  are 
present.  They  may,  however,  be  coexistent.  As  a  rule,  prostator- 
rhcea is  due  to  relaxation  of  the  prostatic  ducts.  This  diminution  in 
muscular  tonicity  is  often  referable  to  a  previous  gonorrhoea,  which 
has  extended  to  the  ducts  and  caused  a  thickening  of  their  walls  which 
keeps  them  from  coming  into  close  apposition.  This  relaxation  may 
also  be  caused  by  masturbation. 

I  desire  to  call  attention  to  a  symptom  of  this  malady  which  is  little 
known,  namely,  the  occurrence  of  residual  urine  in  young  men  in 
whom  no  cause  for  its  existence  is  to  be  found.     It  is  probably  due 


318  DISEASES    OF    THE    PROSTATE    GLAND. 

to  contraction  of  the  sphincter  caused  by  the  prostatic  trouble,  as  a 
result  of  which  the  bladder  cannot  completely  empty  itself. 

I  have  frequently  observed  another  important  symptom  in  chronic 
prostatitis  which  was  first  described  by  Ultzmann,  that  is,  the  expulsion 
of  sandy  masses  with  the  last  drops  of  urine.  They  are  sometimes 
of  large  size,  so  that  they  cause  considerable  pain.  They  are  com- 
posed of  phosphate  and  carbonate  of  lime  which  incrustate  pus- cells, 
and  also  are  voided  by  themselves,  appearing  as  free  amorphous  masses 
when  viewed  through  the  microscope.  These  calcareous  particles 
are  forced  out  of  the  excretory  ducts  of  the  prostate  into  the  urethra 
by  contractions  of  the  sphincter.  It  is  generally  conceded  that  phos- 
phaturia  is  frequently  associated  with  prostatorrhcea. 

Finally,  there  remains  to  be  mentioned  as  important  objective 
symptoms,  the  results  obtained  by  palpating  the  prostate  through  the 
rectum.  In  those  cases  in  which  nothing  but  a  superficial  catarrh 
of  the  excretory  ducts  of  the  prostate  is  present — cases  to  which  Fur- 
bringer  does  not  even  apply  the  term  prostatitis — it  is  evident  that 
no  deviations  from  the  normal  will  be  elicited  by  palpation. 

In  other  cases,  however,  it  is  plainly  recognized  that  the  gland  is 
enlarged  either  in  its  totality  or  in  single  portions.  Projecting  areas 
alternate  with  even  surfaces  and  with  depressions  which  manifestly 
correspond  to  places  in  which  contraction  has  superseded  loss  of 
substance.  The  consistency  is  not  uniform,  being  hard  in  some 
portions  and  soft  in  others;  the  soft  areas  represent  parenchymatous 
degeneration,  the  firm  portions  cicatricial  contraction.  The  surface 
of  the  gland,  as  already  stated,  is  seldom  even  as  in  health,  but  irregu- 
lar and  rough.  Nothing  definite  can  be  stated  as  to  painfulness. 
Palpation  of  a  normal  prostate  is  painful,  but  I  -have  examined 
many  patients  with  prostatitis  in  whom  the  normal  sensibility  was 
not  increased. 

The  same  may  be  said  of  urethral  examination  with  metal  sounds. 
As  healthy  persons  are  frequently  very  sensitive  to  this  manipulation 
it  is  difficult  to  determine  whether  the  sensibility  manifested  by  the 
subjects  of  prostatitis  is  or  is  not  in  excess  of  the  normal. 

The  endoscope  imparts  no  information,  because  its  introduction 
into  the  posterior  urethra  produces  so  many  artificial  conditions  that 
it  is  impossible  to  discriminate  between  that  which  is  extrinsic  and 
that  which  is  due  to  the  prostatic  inflammation.  Moreover,  nothing 
can  be  learned  of  conditions  beyond  the  orifice  of  the  prostatic  ducts. 


CHRONIC    PROSTATITIS.  319 

I  advise  against  this  method  of  examination;  it  is  injurious  instead  of 
advantageous. 

Cystoscopy,  on  the  other  hand,  reveals  characteristic  changes  at 
the  vesical  sphincter.  The  border  is  not  even  as  in  health,  but  uneven 
and  fringed,  showing  prominences  and  large  arches.  These  abnor- 
malities are  due  to  the  fact  that  the  irregularly  enlarged  prostate  has 
here  and  there  distorted  the  mucous  membrane  covering  the  sphincter. 

Treatment.  The  treatment  of  chronic  prostatitis  is  not  an  easy 
task.  As  concerns  the  milder  forms  which  give  rise  to  no  symptoms, 
and  which  are  brought  to  light  only  when  examination  of  the  filaments 
voided  with  the  urine  is  made,  treatment  is  required  only  when  the 
nature  of  the  filaments  is  such  as  to  demand  its  institution.  If 
the  filaments  consist  of  epithelial  cells  and  a  few  leucocytes,  and  if 
repeated  examination  shows  them  to  be  free  from  microorganisms, 
no  treatment  is  necessary.  Too  much  attention  to  the  condition  of 
these  patients  leads  them  to  believe  that  they  are  afflicted  with  a  serious 
malady,  and  thus  makes  them  nervous.  These,  the  mildest  forms  of 
chronic  prostatitis,  may  persist  for  years  without  occasioning  the 
slightest  harm. 

If,  on  the  contrary,  the  secretion  of  pus  from  the  prostate  be  so 
great  as  to  cause  the  previously  described  intermittent  pyuria  and 
bacteriuria,  then,  of  course,  treatment  is  indicated.  It  consists  in  regular 
irrigation  of  the  bladder  with  nitrate  of  silver  solution  1 15000-1 :  1000, 
or  sublimate  solution  1 :  10000,  and  massage  of  the  prostate. 

Massage  of  the  prostate  is  the  most  efficient  means  we  possess 
for  treating  chronic  prostatitis.  Because  of  the  inaccessibility  of  the 
prostate  it  is  evident  that  a  suppurative  process  affecting  the  organ 
will  be  very  difficult  to  influence.  By  regular  massage  and  expression 
of  the  secretion,  which,  however.,  must  be  continued  for  months, 
the  process  can  be  much  ameliorated,  and  occasionally  entirely  cured. 

At  first  massage  is  painful  and  therefore  must  be  sparingly  practised. 
As  soon  as  the  patient  becomes  accustomed  to  it,  however,  sufficient 
pressure  may  be  exerted  to  force  large  quantities  of  prostatic  fluid  out 
into  the  urethra.  In  comparison  with  massage  all  other  measures  play 
a  subordinate  role. 

The  causative  conditions  must  also  be  treated.  Strictures,  urethral 
discharges,  purulent  vesical  catarrh,  calculi,  and  any  other  abnormal 
condition  must  be  attended  to.  Treatment  of  the  urethra,  however, 
must  not  be  continued  too  long.     It  is  justifiable  only  as  far  as  it  is 


320  DISEASES    OF    THE    PROSTATE    GLAND. 

directed  to  the  removal  of  the  condition  which  is  responsible  for  the 
prostatic  trouble,  and  when  this  condition  is  overcome  then  the  urethral 
treatment  should  be  stopped,  for  it  will  not  cure  the  prostatitis.  An 
exception  to  this  rule  is  to  be  made  concerning  cauterization  of  the 
colliculus  seminalis  and  its  environs,  as  a  few  caustic  applications 
to  this  region  exert  a  very  favorable  action,  especially  in  the  forms 
associated  with  prostatorrhcea,  precocious  ejaculation,  and  uncom- 
fortable sensations  in  the  posterior  urethra  and  perineum. 

I  have  not  seen  any  great  results  from  medication,  either  from  the 
internal  use  of  drugs  or  from  local  applications  in  the  form  of  sup- 
positories. The  use  of  ichthyol  and  iodine,  particularly  the  latter, 
appears  to  me  to  be  the  most  rational.  Suppositories  of  iodine  and 
potassium  iodide  may  be  prescribed,  and  their  employment  continued 
for  months.  In  order  to  preserve  the  bladder  from  infection  by  the  fre- 
quently discharged  purulent  masses  it  is  well  to  let  the  patient  take 
0.5  [7^  grains]  of  uro tropin  three  times  a  day. 

If  the  pain  becomes  intolerable  narcotics  may  be  occasionally  used, 
but  caution  should  be  exercised  in  giving  them,  the  same  as  in 
all  other  chronic  diseases,  lest  a  drug-habit  be  superimposed  upon 
the  already  existing  trouble.  As  a  rule,  the  pain  is  not  so  severe  as 
to  call  for  the  administration  of  narcotics.  In  most  cases  it  can  be 
controlled  by  antipyrine,  phenacetine,  and  pyramidon,  the  last  of 
which  exerts  a  particularly  sedative  action. 

As  local  measures  I  recommend  the  injection  of  hot  saline  solution, 
or  the  introduction  of  a  heat-diffusing  apparatus  into  the  rectum, 
the  use  of  the  thermophore  catheter  in  the  urethra,  and  faradization 
of  the  prostate. 

The  hot  injections  are  made  of  200  cc.  [7  fluid  ounces]  of  water  as 
hot  as  the  rectum  can  endure,  to  which  are  added  salt,  Kreuznacher 
salt,  and  Darkauer  iodine-bromine  salt  in  increasing  quantities.  They 
produce  very  little  irritation  of  the  rectum. 

If  a  more  protracted  action  of  heat  be  desired  Finger's  or  Atzbergers 
irrigator  may  be  used,  by  means  of  which  a  stream  of  hot  water  can 
be  made  to  flow  through  the  rectum.  A  more  agreeable  method  of 
applying  heat  is  by  the  use  of  a  pear-shaped  thermophore  which  I  have 
had  made,  and  which  retains  its  heat  from  fifteen  minutes  to  half  an 
hour.  This  instrument  has  proved  itself  of  service,  especially  as  the 
patient   can  learn  to  use  it  himself. 

Winternitz's  urethral  psychrophore  may  also  be  employed,  but  hot 


CHRONIC    PROSTATITIS.  321 

water  should  be  used  instead  of  cold,  the  temperature  being  gradually 
increased  until  as  high  a  degree  as  the  patient  can  bear  is  reached. 

Faradization  of  the  prostate  is  performed  by  introducing  one  electrode 
into  the  rectum  and  placing  the  other  over  the  pubes.  Instead  of  the 
usual  rectal  electrode  the  rectal  thermophore,  which  is  also  equipped 
for  electrization,  may  be  used. 

By  means  of  these  various  measures  the  subjective  symptoms 
especially  are  greatly  benefited;  objective  symptoms,  however, 
are  only  slightly  influenced.  The  most  potent  factor  is  massage, 
which  gradually  reduces  the  suppurative  process,  although  the  pros- 
tatic fluid  will  scarcely  ever  be  found  entirely  free  from  pus-cells. 
A  small  amount  of  pus  usually  persists,  but  it  can  be  left  to  itself,  as 
it  does  no  harm  whatever. 

Injections  of  carbolic  acid  into  the  prostate  through  the  rectum, 
and  cauterization  with  the  Bottini  instrument  are  dangerous  and 
should  not  be  used;  for  although  prostatitis  certainly  is  difficult  to 
cure  it  is  not  a  grave  malady. 

General  hygienic  measures  are  of  value,  particularly  if  nervous 
phenomena  are  marked.  The  relinquishment  of  work  and  resi- 
dence in  a  sanitarium  where  mild  hydrotherapeutic  treatment  can  be 
obtained  often  have  a  very  favorable  effect.  If  the  patient  cannot 
afford  this  a  general  hygienic-dietetic  cure  may  be  undertaken  at 
home.  The  diet  should  be  regulated  and  simple  food  ordered.  Highly 
seasoned  food,  as  well  as  any  which  produces  flatulence,  should  be 
interdicted.  Daily  evacuation  of  the  bowels  must  be  secured.  The 
upper  portion  of  the  body  should  be  massaged  one  day  and  the  ex- 
tremities the  next.  Sitz-baths  of  alternating  temperature  are  useful 
for  stimulating  the  circulation.  The  patient  sits  in  a  tub  of  water 
at  a  temperature  of  350  C.  [950  F.]  and  then  hot  water  is  added  every 
minute  or  two  until  the  temperature  is  raised  to  420  or  430  C.  [107. 6° 
or  109.40  F.].  The  next  day  water  at  a  temperature  of  40  C.  [1040  F.] 
is  begun  with  and  gradually  cooled  to  250  C.  [770  F.]. 

All  the  above  mentioned  measures  must  not  be  employed  indis- 
criminately, but  used  in  moderation  and  for  definite  objects;  other- 
wise we  shall  overtreat  our  patients  and  do  them  harm.  It  is  as  bad 
to  overtreat  them  as  it  is  to  let  them  go  untreated.  It  must  be  borne  in 
mind  that  the  disease  is  often  of  a  nervous  character,  even  though  the 
changes  in  the  prostate  supplied  the  foundation  of  the  neurosis;  that 
we  can  only  slightly  influence  the  prostatic  disease;  that  in  many  cases 


32  2  DISEASES    OF    THE    PROSTATE    GLAND. 

it  is  self -limited;  that  in  the  anatomical  sense  it  seldom  is  serious  in 
its  results,  and  that  for  these  reasons  our  chief  effort  must  be  to  con- 
vince the  patent  that  he  does  not  have  a  dangerous  disease,  but  only  a 
slight  variation  from  the  normal,  such  as  often  exists  in  other  organs 
of  the  body. 

HYPERTROPHY  OF  THE  PROSTATE. 

Hypertrophy  of  the  prostate  is  such  a  common  disease  that  there 
are  practical  reasons  for  according  it  special  consideration. 

Generally  speaking  prostatic  hypertrophy  consists  in  an  increase 
in  volume  and  alterations  in  form  of  the  prostate  gland,  which  normally 
is  the  size  of  a  chestnut.  What  causes  this  increase  in  volume  is  a 
matter  concerning  which  the  most  varied  opinions  are  still  held.  The 
etiology  and  pathologic  anatomy  of  the  disease  stand  in  such  close 
relation  to  one  another  that  they  must  be  discussed  together. 

If  we  confine  ourselves  to  that  which  experience  teaches,  we  see 
that  there  are  two  kinds  of  prostatic  enlargement,  a  hard  and  a  soft, 
the  first  being  due  to  hypertrophy  of  the  connective  and  muscular 
stroma,  the  second  to  hyperplasia  of  the  glandular  elements.  The 
condition,  then,  is  one  of  idioplastic  benign  growth,  that  is,  one  in 
which  only  those  elements  normally  present  in  the  gland  increase  and 
multiply,  thus  differing  from  malignant  tumors,  which  are  characterized 
by  their  heteroplasia. 

We  distinguish  three  forms  of  prostatic  hypertrophy: — i.  the  cir- 
cumscribed or  nodose  myomatous;  2.  the  diffuse  myomatous;  3.  the 
adenoid  or  glandular. 

These  three  forms  present  characteristic  differences  when  examined 
macroscopically,  and  these  differences  are  also  observed  when  the 
gland  is  studied  microscopically. 

In  the  first  form,  the  hyperplastic  myoma  of  Virchow,  the  cut 
surface  of  the  gland  shows  well-marked  protruding,  spherical  nodules, 
white  or  grayish-yellow  in  color,  between  which  there  are  softer 
areas  of  a  yellow  or  yellowish-red  color,  containing  here  and  there  a 
few  brown  or  black  granules,  varying  from  the  minutest  dots  to  specks 
the  size  of  a  hemp-seed.  The  firm,  prominent  nodules  are  typical 
myomata  or  fibromyomata,  which  can  often  be  enucleated;  the  softer 
areas  represent  undiseased  glandular  substance,  and  the  brown  or 
black  granules  are  pigmented  amylaceous  corpuscles  containing 
degenerated  and  thickened  prostatic  secretion  in  their  center. 


HYPERTROPHY    OF    THE    PROSTATE. 


323 


These  changes  can  be  much  more  plainly  recognized  under  the 
microscope.  The  fibro-muscular  tissue  of  the  nodules,  in  which 
some  traces  of  glandular  substance  still  remain,  can  be  clearly  seen 
(see  Figures  177  and  178,  representing  a  normal  and  a  fibromyomatous 
prostate  respectively).  Socin  has  called  attention  to  the  fact  that 
this  myomatous  hyperplasia  and  hypertrophy  proceeds  from  the  smooth 
muscle  fibers,  large  numbers  of  which  accompany  the  glandular  ducts. 
This  form  of  hypertrophy  is  by  far  the  most  common. 

The  diffuse  fibro-myomatous  form  differs  from  the  one  just  described 
in  that  the  fibro-muscular  overgrowth  does  not  occur  as  nodules,  but 


-Cross  section  of  normal  adult  prostate  showing  numerous 
ducts  separated  by  thin  musculo-fibrous  septa. 


as  a  diffuse  filamentous  striation  of  a  gray  or  white  color,  which  stands 
out  sharply  from  the  darker-hued  surrounding  tissue,  and  gives  the 
organ  a  dendritic  appearance.  If  slight  pressure  be  made  upon  the 
gland  very  little  or  no  fluid  will  exude,  it  differing  in  this  respect  from 
the  circumscribed  form,  in  which  a  yellow,  mucoid  mass  can  almost 
always  be  expressed.  When  examined  microscopically  the  fasciculi 
are  found  to  consist  of  connective  tissue  fibers,  which  are  only  slightly 
nucleated,  and  of  muscle  fibers,  with  obliterated  and  distorted  glandular 
ducts  between  the  two.  In  comparison  with  the  connective  tissue, 
the  glandular  substance  is  considerably  reduced  in  quantity. 


324 


DISEASES    OF    THE    PROSTATE    GLAND. 


The  third  form,  glandular  hypertrophy,  represents  a  typical 
adenomatous  growth,  the  glandular  substance  undergoing  hyper- 
trophy and  hyperplasia,  while  the  fibro-muscular  stroma  remains 
unaffected.  This  morbid  process  may  also  be  diffuse  or  circum- 
scribed, the  latter  form  being  by  far  the  more  common. 

The  cut  surface  of  such  a  prostate  is  spongy,  soft,  and  of  a  grayish- 
red  color.  Slight  pressure  causes  a  copious  outflow  of  yellow  fluid. 
The  glandular  ducts  are  widely  dilated;  their  epithelium  is  well 
preserved.     Some  of  the  acini  are  converted  into  cysts,  which  contain 


Fig.  178. — Hypertrophy  of  the  prostate.  Some  of  the  ducts  are  atrophied 
and  some  are  filled  with  stratified  bodies.  The  glandular  substance  has  been 
destroyed  by  the  increasing  fibro-muscular  tissue,  which  takes  up  the  greater 
part  of  the  field. 

disintegrated  epithelium  and  the  stratified  amyloid  bodies.     All  in  all 
this  form  is  very  rare. 

[Some  investigators  have  found  the  adenomatous  form  to  be  com- 
paratively common,  and  others  assert  that  it  occurs  more  frequently 
than  the  myomatous  or  fibrous.  Greene  and  Brooks,  however,  in  an 
examination  of  fifty-eight  specimens,  found  the  fibrous  variety  to 
predominate.  It  is  evident  that  further  study,  based  on  an  examina- 
tion of  a  large  number  of  diseased  prostates  representing  various  stages 
of  hypertrophy,  will  be  necessary  in  order  to  settle  the  question.] 


HYPERTROPHY    OF    THE    PROSTATE.  325 

Thus  it  is  seen  that  an  active  process  of  overgrowth  is  common 
to  all  three  forms,  whether  it  affects  the  stroma  or  the  parenchyma. 

What,  now,  is  the  cause  of  this  proliferative  process  leading  to 
enlargement  of  the  organ?  As  has  already  been  stated  the  opinions 
on  this  matter  are  greatly  at  variance.  In  the  first  place  it  may  be 
said  that  the  most  comprehensive  reasons  have  been  given,  such  as 
diathesis  (gout,  scrofula,  rheumatism),  local  irritation  resulting  from 
catheterization  or  sexual  excess,  occupations  which  entail  constant 
sitting,  constipation,  and  the  abuse  of  alcohol.  These  hypotheses 
are  so  vague  and  so  entirely  unfounded  on  the  results  of  experience 
that  they  may  be  dismissed  as  untenable. 

Launois,  a  pupil  of  Guyon's,  advanced  the  hypothesis,  which  he 
derived  from  anatomical  investigation,  that  the  disease  is  merely  a 
part  of  universal  arteriosclerosis,  or  local  arteriosclerosis  affecting  the 
urinary  organs,  and  that  the  accompanying  retention  of  urine  is  not 
a  result  of  the  prostatic  disease,  but  an  associated  phenomenon  evoked 
by  arteriosclerosis  of  the  wall  of  the  bladder. 

I  proved  this  theory  to  be  incorrect  fifteen  years  ago,  showing  that 
hypertrophy  of  the  prostate  exists  independently  of  vesical  or  prostatic 
arteriosclerosis,  and,  conversely,  that  arteriosclerosis  occurs  without 
hypertrophy  of  the  prostate.  Both  are  affections  of  old  age,  and 
therefore  are  often  associated,  but  they  bear  no  causal  relation  to 
one  another. 

The  correctness  of  this  assertion  is  confirmed  by  clinical  experience, 
which  teaches  that  in  many  cases  in  which  complete  retention  of  urine 
has  existed  for  years  the  contractile  power  of  the  bladder  remains 
unweakened.  This  would  be  impossible  were  the  wall  of  the  bladder 
much  affected  with  sclerotic  degeneration. 

Ciechanowski,  in  a  very  diligent  investigation  of  the  subject,  has 
recently  endeavored  to  prove  that  prostatic  hypertrophy  is  merely  the 
terminal  result  of  chronic  gonorrhceal  inflammation.  This  theory 
likewise  is  not  valid;  neither  the  history  of  cases  nor  pathological 
investigation  lend  it  support.  In  fact  the  exact  reverse  is  true.  It  is 
certain  that  there  are  men  who  have  had  gonorrhoea  and  prostatitis 
for  years  without  getting  prostatic  hypertrophy,  and,  conversely,  I 
know  many  persons  with  enlarged  prostates  who  never  had  gonorrhoea. 

If  considered  from  the  standpoint  of  pathological  anatomy,  it 
would  naturally  be  supposed  that  if  gonorrhoea  and  prostatitis  were 
causative  factors  in  the  production  of  prostatic  hypertrophy,  evidence 


326  DISEASES    OF    THE    PROSTATE    GLAND. 

of  them  would  be  found  in  the  posterior  urethra.     Such,  however, 
is  not  the  case. 

Ciechanowski's  views  may  perhaps  be  explained  by  the  fact  that 
prostatitis  is  occasionally  accompanied  by  considerable  enlargement 
of  the  prostate,  under  which  circumstances  the  disease  may  simulate 
hypertrophy  both  clinically  and  anatomically.  But  this  is  exceptional, 
for  prostatitis,  the  same  as  ever}'  chronic  inflammatory  process,  generally 
leads  to  destruction  of  the  parenchyma,  contraction  of  the  connective 
tissue,  and  atrophy. 

Rovsing  still  contends  that  the  morbid  process  is  one  of  myomatous 
overgrowth;  he  sides  with  those  who  favor  the  theory  of  glandular 
hyperplasia. 

I  am  of  the  opinion  that  the  cause  of  the  three  forms  of  prostatic 
hypertrophy  is  as  yet  entirely  unknown;  we  know  just  as  little  about 
its  cause  as  we  do  about  the  cause  of  other  tumors,  benign  and  malig- 
nant. We  only  know  that  it  is  a  senile  change  which  seldom  mani- 
fests itself  before  the  fiftieth  year. 

In  order  to  account  for  the  apparent  inconsistency  of  the  prostate 
undergoing  active  hypertrophy  at  a  period  of  life  when  retrogressive 
and  atrophic  changes  are  taking  place,  Rovsing  assumes  that  the 
glandular  hypertrophy  is  an  effort  on  the  part  of  nature  to  compen- 
sate a  beginning  senile  insufficiency,  an  attempt  being  made  to  over- 
come the  poor  quality  of  the  prostatic  secretion  by  increasing  its 
quantity. 

Overgrowth  of  the  glandular  substance,  however,  is  rare;  it  is 
usually  destroyed,  the  stroma  being  the  portion  which  hypertrophies. 
Therefore  it  seems  to  me  that  Rovsing's  hypothesis  is  untenable.  I 
do  not  believe  that  the  idea  of  the  gland  undergoing  hypertrophy 
at  an  advanced  period  of  life  is  at  variance  with  our  knowledge  of 
pathology,  for  other  tumors,  particularly  the  malignant,  which  cer- 
tainly show  a  high  degree  of  activity,  are  especially  prone  to  occur 
during  old  age. 

Finally,  it  must  be  declared  that  hypertrophy  of  the  prostate  does 
not  always  begin  between  the  ages  of  sixty  and  seventy,  as  has  fre- 
quently been  stated.  It  is  true  that  the  disease  generally  manifests 
itself  after  the  age  of  fifty.  This  is  probably  largely  due  to  the  fact 
that  in  the  earlier  stages  of  its  development  it  produces  no  symptoms. 
I  have,  however,  often  seen  considerable  enlargement  of  the  prostate  as 
early  in  life  as  the  middle  and  even  the  beginning  of  the  fourth  decade. 


HYPERTROPHY  OF  THE  PROSTATE. 


327 


In  this  respect  the  statistics  of  my  honored  teachers,  Thompson 
and  Guyon,  are  very  instructive.  They  show  that  34  per  cent  of 
all  cases  occur  after  the  sixtieth  year,  but  that  only  from  50  per  cent 
to  60  per  cent  of  this  number  cause  any  symptoms  of  illness. 

Furthermore,  it  is  seen  from  these  investigations  that  no  definite 
relation  exists  between  the  size  of  the  prostate  and  the  difficulty  which 
is  produced.  Persons  having  a  very  large  prostate  may  have  little 
or  no  trouble  from  it,  while  comparatively  slight  hypertrophy  may 
cause  unbearable  suffering  (see  Figure  179). 

It  follows,  then,  that  hypertrophy  of  the  prostate  is  in  itself  an 


Fig.  179. — Hypertrophied  prostate  from  a  man  aged  sixty-eight  years, 
which  produced  no  symptoms  during  life.     (Giiterbock.) 


abnormality,  but  not  necessarily  a  disease  any  more  than  is  a  small 
lipoma  on  the  arm.  It  is  only  when  the  reaction  of  the  enlarged 
gland  upon  the  urinary  organs  gives  rise  to  disturbances  that  the 
condition  becomes  a  disease,  and  then,  indeed,  one  which  is  often  of 
great  severity. 

Therefore  it  is  especially  desirable  thoroughly  to  understand  what 
alterations  in  the  urinary  organs  and  the  function  of  micturition  are 
produced  by  the  enlarged  gland. 

The  macroscopic  changes  concern  form,  size  and  weight. 

The  normal  prostate  is  shaped  like  a  chestnut;  increase  in  thickness 


328 


DISEASES    OF    THE    PROSTATE    GLAND. 


causes  it  to  assume  a  spherical  shape.  Its  normal  weight  is  between 
15  and  20  grammes  [225  and  300  grains].  In  hypertrophy  it  is  not 
unusual  for  it  to  attain  a  weight  of  80  grammes  [1200  grains].  Excep- 
tionally it  may  be  much  larger,  and  Gross  has  recorded  a  case  in  which 
it  weighed  288  grammes  [4320  grains]. 

The  prostate  may  hypertrophy  in  its  entirety  or  in  single  portions, 
and  the  overgrowth  may  be  either  symmetrical  or  asymmetrical. 

If  the  whole  gland  enlarges  symmetrically  (Fig.  180),  a  large, 
regular,  spherical  mass  extending  equally  on  either  side  and  protrud- 


Fig.  180. — Total  hypertrophy  of  the  prostate. 

ing  backward  into  the  rectum  can  be  felt  by  rectal  palpation.  The 
groove  between  the  two  lateral  lobes  is  obliterated,  the  base  of  the 
bladder  is  pushed  upwards  by  the  upward  bulging  of  the  gland,  and 
the  orifice  of  the  urethra  is  likewise  carried  upwards  so  that  it  no 
longer  occupies  the  lowest  point  in  the  bladder. 

When  the  enlargement  is  asymmetrical  one  lobe  is  larger,  broader, 
or  extends  further  backwards  than  the  other.  If  the  median  portion 
develops  excessively,  a  so-called  third  lobe  is  formed;  this  condition 
was  first  described  by  Sir  Everard  Home,  and  for  this  reason  the 
name  of  Home's  lobe  has  been  applied  to  it. 


HYPERTROPHY    OF    THK    PROSTATE. 


329 


According  to  some  authors  this  form  of  hypertrophy  results  from 
proliferation  of  pre-existing  accessory  glandular  elements  situated 
immediately  at  the  urethral  orifice.  This  third  lobe  plays  an  important 
role  in  the  pathology  of  prostatic  hypertrophy.  It  may  attain  enormous 
dimensions;  I  have  seen  it  vary  in  size  from  a  protuberance  as  large 
as  a  pea  to  a  mass  as  large  as  a  small  apple.  It  may  be  either  pedun- 
culated or  sessile. 


Fig.  181. — Hypertrophy  of  the  prostate,  a  and  a'  show  the  left  lobe,  which 
is  the  more  enlarged  of  the  two.  a'  represents  the  portion  covered  by  the 
urethral  and  vesical  mucosa,  b  right  lobe.  The  urethra  is  displaced  toward 
the  right.  A  middle  lobe  and  catheters  projecting  from  the  ureters  are  also 
shown.     (Viertel.) 


The  portion  of  the  gland  lying  anterior  to  the  urethra,  between  it 
and  the  symphysis,  is  rarely  the  seat  of  hypertrophy. 

The  changes  which  the  bladder  and  urethra  suffer  through  the 
enlargement  of  the  prostate  are  of  great  practical  interest,  and  should 
be  thoroughly  understood.  The  prostatic  urethra  is  altered  in  caliber, 
shape  and  length. 


66" 


DISEASES    OF    THE    PROSTATE    GLAND. 


The  normal  length  of  the  urethra  is  about  20  cm.  [8  inches], 
the  prostatic  portion  being  from  2  to  3  cm.  [|  to  il  inches].  When 
the  prostate  forces  the  bladder  upwards  the  urethral  portion  is  carried 
up  with  it  and  the  neck  of  the  bladder  is  much  higher  than  normal. 
The  displacement  is  often  so  great  that  an  ordinary  catheter  is  too 
short  to  reach  into  the  bladder.  I  have  known  such  a  displacement 
to  measure  9  cm.  [3!  inches],  the  entire  length  of  the  urethra  being 
30  cm.  [12  inches]. 

The  prostatic  urethra  also  undergoes  a  considerable  alteration  in 
caliber.     If  both  lateral  lobes  become  closely  approximated  as  the 


B 

Fig.  182. — Different  forms  of  deviation  of  the  urethra  in  hypertrophy  of  the 
prostate.  (Thompson.)  a  the  right,  b  left,  c  middle  lobe.  Dotted  lines  show  the 
direction  for  the  catheter  to  take. 


result  of  overgrowth,  the  urethra  may  be  so  narrowed  that  the  use  of 
a  certain  amount  of  force  is  required  to  pass  a  catheter  through  the 
constriction.  It  feels  as  though  the  instrument  were  being  forced 
through  a  stricture.  Often,  however,  an  opposite  condition  exists. 
The  urethra  is  extended  over  the  mass.  If,  for  example,  it  is  chiefly 
the  posterior  portion  of  the  prostate  which  is  enlarged,  the  posterior 
wall  of  the  urethra  will  be  distorted  in  such  a  manner  as  to  produce 
ampulla-like  dilatations,  which  may  be  so  large  that  the  beak  of  the 
catheter  can  be  turned  as  much  as  3600  on  its  axis.  Inasmuch  as  this 
manipulation  is  generally  considered  proof  that  the  catheter  is  in  the 


HYPERTROPHY  OP  THE  PROSTATE. 


33T- 


bladder,  it  is  evident  that  this  dilatation  of  the  urethra  may  lead  to 
very  serious  errors  in  diagnosis  unless  its  existence  be  recognized. 

If  one  lateral  lobe  hypertrophies  greatly  while  the  other  does  not 
enlarge  the  first  will  push  the  urethra  toward  the  opposite  side  (Fig.  181). 
This  produces  lateral  deviation  of  the  course  along  which  the  catheter 
has  to  pass.  If  several  of  these  deviations  are  present,  the  urethra 
is  made  to  assume  an  S-shaped  form,  a  circumstance  which  may  make 


Y-shaped 
urethra. 


Fig.  183. 

catheterization  very  difficult.  Finally,  if  a  wedge-shaped  projection 
of  the  prostate  into  the  median  line  occurs,  a  bifurcation  of  the  urethra 
takes  place  in  such  a  manner  that  a  Y-shaped  passage  is  formed 
(Figs.  182  and  183). 

In  addition  to  these  changes,  which  alter  the  perviousness  of  the 
urethra  to  instruments — and  that  to  a  degree  often  incalculable — 
changes  in  its  shape  also  occur.     The  posterior  urethra  is  usually 


332  DISEASES    OF    THE    PROSTATE    GLAND. 

more  curved  than  in  health.  As  the  hypertrophy  of  the  gland  does 
not  exert  an  equal  effect  on  different  portions  of  the  urethra,  because 
the  hypertrophied  portions  are  not  evenly  disposed  around  it,  and 
furthermore  because  it  is  firmly  fixed  to  the  perineal  fascia  below  and 
the  symphysis  in  front,  it  is  evident  that  the  lateral  and  posterior 
portions  will  yield  more  than  the  superior  part. 

The  radius  of  the  circle  which  the  prostatic  urethra  then  forms 
is  shorter  than  the  normal,  but  the  sector  of  the  circle  is  larger.  When 
the  median  portion  of  the  prostate  is  excessively  developed,  the  sector 
"may  equal  more  than  half  the  circumference  of  a  circle,  so  that  the 
catheter  can  be  bent  into  a  circle  and  yet  not  reach  the  bladder,  being 
turned  back  against  the  symphysis  instead."  (Socin).  Indeed,  in 
extreme  cases  the  posterior  urethra  may  be  so  bent  as  to  form  an 
angle  instead  of  an  arch,  thus  producing  a  condition  which  may  render 
catheterization  impossible. 

From  this  description  it  will  be  seen  that  all  the  changes,  but  par- 
ticularly those  concerning  the  caliber  and  shape  of  the  urethra,  take 
place  at  the  expense  of  the  inferior  wall  of  the  canal,  while  the  anterior 
superior  wall  remains  practically  unchanged,  its  curve  hardly  differing 
from  the  normal.  It  cannot  be  bent,  it  cannot  be  made  to  deviate 
materially  from  its  course;  therefore,  the  old  rule  that  in  every  diffi- 
cult catheterization  the  tip  of  the  instrument  should  be  held  against 
the  anterior  (upper)  wall  of  the  urethra,  is  well  worth  remembering. 

A  more  difficult  but  more  important  matter  in  the  pathology  of 
prostatic  hypertrophy  is  the  condition  of  the  internal  vesical  sphincter 
and  of  the  so-called  middle  lobe  situated  within  and  above  it. 

In  the  first  place  it  must  be  remembered  that  valves  at  the 
neck  of  the  bladder  may  occur  independently  of  enlargement  of 
the  prostate.  To  this  form  of  valve  Lienhard  has  applied  the 
name  luette  vesicate,  and  Amussat  uses  the  term  vidvula  vesico 
urethralis.  Concerning  these  valves  Henle  says  that  the  longitu- 
dinal elevation  of  the  trigonum  of  Lieutaud  becomes  more  pro- 
nounced as  it  approaches  the  urethral  orifice,  and  that  its  highest  point 
lies  within  the  urethra,  so  that  when  the  growth  is  especially  large  a 
semilunar  cleft  having  its  convexity  forward  is  formed.  Dittel  denies 
the  existence  of  such  valves,  but  Thompson,  Virchow,  and  Socin  recog- 
nize them.  It  is  important  to  remember,  as  Konig  has  shown,  that 
these  valves  at  the  neck  of  the  bladder  may  constitute  a  material 
impediment  to  the  emptying  of  the  bladder.     This  is  especially  true 


HYPERTROPHY  OF  THE  PROSTATE. 


333 


when  besides  the  valve  there  is  an  invagination  of  the  bladder  behind 
the  internal  meatus. 

Similar  barrier-like  valves  are  formed  by  the  middle  lobe  of  an 
enlarging  prostate.  It  has  long  been  known  that  this  intravesical 
prostatic  tumor  may  become  an  insurmountable  impediment  to  the 
emptying  of  the  bladder.  Contractions  of  the  detrusor  vesicae, 
which  otherwise  are  followed  by  relaxation  of  the  sphincter  and  opening 
of  the  bladder,  press  the  prostatic  tumor  directly  into  the  urethral 


Fig.  184. — Hypertrophy  of  the  prostate,  especially  of  the  middle  lobe, 
which  projects  into  the  bladder  like  a  ball.     (Viertel.) 

orifice  and  completely  close  it  (Figures  184  and  185).  It  is  very  character- 
istic that,  in  contradistinction  to  stricture  of  the  urethra,  in  this  con- 
dition the  harder  the  patient  strains  the  more  difficult  micturition 
becomes.  This  is  due  to  the  fact  that  the  stronger  contractions  increase 
the  solidity  of  the  closure. 

These  middle  lobes  vary  as  to  their  size  and  form.  Small  warty 
growths,  slight  elevations  from  the  size  of  a  pea  to  a  bean,  alternate 
with  linguiform  tumors  and  large,  solid,  sessile  growths  as  big  as  an 


334 


DISEASES    OF    THE    PROSTATE    GLAND. 


apple.  I  have  often  seen  several  of  these  middle  lobes  encircling 
the  mouth  of  the  bladder  like  a  wreath  and  making  it  appear  as  though 
two  isolated  tumors  were  present.  I  have  never  known  this  third 
lobe  to  separate  the  sphincter  and  cause  incontinence  of  urine.  When 
incontinence  occurs  in  these  cases  it  is  produced  by  overdistention 
of  the  bladder  of  sufficient  degree  to  cause  the  sphincter  to  open. 

Finally,  there  remains  to  be  mentioned,  the  so-called  muscular  barrier, 
consisting  of  muscle  fibers  of  the  hypertrophied  internal  sphincter 
which  spread  out  between  the  hypertrophied  lateral  lobes.     It  may 


Fig.  185. — Total  hypertrophy  of  the  prostate.     Epiglottis-like  middle 
lobe  which  impedes  the  outflow  of  urine. 

interfere  with  micturition  in  exactly  the  same  manner  as  the  barrier 
which  is  occasionally  formed  in  the  trabecular  bladder  by  hypertrophy 
of  the  interureteral  ligament. 

The  effect  which  this  interference  with  urination  exerts  upon  the 
upper  urinary  tract  does  not  differ  materially  from  that  caused  by 
other  forms  of  obstruction,  notably  stricture.  It  should,  however, 
be  noted  that  the  effect  is  more  severe  and  lasting,  because  the  retention 
of  urine  occurs  in  the  weakened  bladder  of  old  and  often  decrepit 
persons. 


HYPERTROPHY    OF    THE    PROSTATE.  335 

Thus  it  will  be  understood  that  in  the  majority  of  cases  we  shall 
have  to  do  with  distention  of  the  bladder.  The  cavity  of  the  bladder 
becomes  greatly  enlarged  and  its  distensibility  increased. 

As  a  result  of  the  increased  work  which  the  bladder  has  to  do  to  over- 
come the  prostatic  obstruction  its  walls  hypertrophy.  If  the  hypertrophy 
occurs  simultaneously  with  distention  it  is  called  eccentric  hypertrophy. 
The  hypertrophied  muscle  fibers  may  be  seen  on  the  interior  surface 
of  the  bladder  as  trabecular.  Between  these  trabecular  invaginations, 
pockets  and  diverticula  form.  These  pockets  may  be  composed  of 
the  entire  thickness  of  the  bladder  wall,  but  they  frequently  merely 
consist  of  mucous  membrane  with  a  thin  muscular  covering.  Thus 
there  is  danger  of  perforating  the  bladder  if  a  pointed  catheter  enter 
one  of  these  pockets  and  be  forced  against  the  wall.  The  musculature 
of  the  bladder  shows  both  fatty  degeneration  and  connective  tissue 
formation. 

The  engorgement  may  extend  further  upward  to  the  ureters  and 
pelvis  of  the  kidney.  The  pelvis  of  the  kidney  presses  upon  the  sub- 
stance of  the  organ  and  may  lead  to  complete  atrophy,  so  that  a  typical 
hydronephrosis  may  exist  and  only  a  narrow  zone  of  cortical  substance 
remain.  It  is  noteworthy,  however,  that  this  engorgement  of  the  upper 
urinary  tract  is  comparatively  rare.  I  have  made  postmortem  exam- 
ination in  many  cases  in  which  retention  had  existed  for  years,  without 
finding  any  dilatation  of  the  ureters  and  pelvis  of  the  kidney,  nor  any 
alteration  in  the  kidney  itself. 

Changes  in  the  upper  urinary  tract  are  much  more  frequent  when, 
as  unfortunately  often  happens,  infection  of  the  bladder  takes  place. 
Then  ureteritis,  pyelitis  and  pyelonephritis  develop. 

The  prostate  may  also  be  affected  by  other  changes,  as  for  example, 
inflammation,  but  the  latter  condition  is  of  slight  importance  in  com- 
parison with  the  principal  malady.  Only  when  it  leads  to  abscess 
formation  in  the  hypertrophied  prostate  is  it  of  serious  significance. 
As  previously  stated,  prostatic  abscess  greatly  endangers  the  life  of 
old  men  who  suffer  from  hypertrophy  of  the  gland  (See  under  Pros- 
tatic abscess). 

It  is  only  natural  that  the  ejaculatory  ducts,  which  pass  through  the 
prostate,  should  be  frequently  affected  by  the  morbid  process.  They 
may  be  either  distorted,  or  obliterated  completely  so  that  the  semen 
cannot  pass  through  them.  In  such  cases  the  seminal  vesicles  are 
enlarged   and  filled  with  stagnant  semen.     In  view  of  the   usually 


336  DISEASES    OF    THE    PROSTATE    GLAND. 

advanced  age  of  the  patients  this  aspermatism  is  not  of  much 
moment. 

The  circulatory  disturbances  produced  by  the  enlarged  prostate 
are  of  greater  importance.  The  prostate  is  surrounded  by  numerous 
veins  which  communicate  with  the  dorsal  vein  of  the  penis  and  veins 
at  the  base  of  the  bladder.  The  vessels  of  this  prostatic  plexus  have  a 
tendency  in  advancing  age  to  become  dilated  and  varicose.  As  a 
result  of  engorgement  occasioned  by  cold  or  by  excesses  in  drinking  and 
in  venery,  the  prostate  likewise  becomes  engorged  and  infiltrated 
with  serum  throughout  its  entire  substance.  It  is  this  condition  of 
the  prostate  which  causes  the  frequent  acute  though  transitory  attacks 
of  retention. 

The  mucous  membrane  of  the  prostatic  urethra  also  shares  in  the 
infiltration ;  it  is  swollen,  soft,  and  bleeds  readily  as  soon  as  it  is  touched 
by  a  catheter.  The  gland  itself,  which  under  normal  conditions 
is  not  very  vascular,  may  be  traversed  by  dilated  blood-vessels,  so  that 
an  injury  may  result  in  profuse  and  often  uncontrollable  haemorrhage. 
I  have  frequently  seen  such  occurrences,  and,  indeed,  have  had  two 
patients  bleed  to  death  from  this  very  form  of  haemorrhage.  The 
prostate,  or  at  least  the  periprostatic  tissue  through  which  the  peri- 
prostatic plexus  runs,  is  almost  like  a  cavernoma. 

SYMPTOMS,  COURSE  AND  DIAGNOSIS. 

The  disease  is  of  such  long  duration  and  its  individual  phases 
usually  occur  with  such  regularity,  that  it  is  advisable  to  divide  it  into 
several  stages,  as  has  been  done  by  Guyon.  The  first  stage  is  the 
premonitory,  the  second  that  of  retention  without  distention  of  the 
bladder,  and  the  third  retention  with  distention  of  the  bladder.  In 
any  of  these  stages  congestive  and  infective  processes  may  supervene 
and  at  times  alter  the  clinical  picture. 

In  the  first  stage  of  the  disease  the  symptoms  are  ordinarily  so  slight 
that  comparatively  few  patients  take  any  notice  of  them.  They  con- 
sist of  scarcely  more  than  a  slightly  increased  desire  to  urinate,  which 
is  experienced  during  the  day  as  well  as  at  night,  an  occasional  slight 
burning  in  the  urethra,  and  a  little  delay  in  starting  the  stream  of 
urine.  This  sign  of  interference  with  micturition  is  more  pronounced 
when  the  bladder  has  not  been  emptied  for  some  hours,  so  that  the 
patient's  attention  is  unpleasantly  attracted  to  it  when  he  arises  in  the 


HYPERTROPHY  OF  THE  PROSTATE.  337 

morning.  During  the  day,  when  the  patient  is  active,  the  flow  of  urine 
becomes  free  again. 

The  urine  is  clear.  The  general  health  is  in  no  wise  impaired. 
The  urinary  stream  has  lost  some  of  its  power  of  projection,  falling 
more  perpendicularly  to  the  feet  of  the  patient.  As  the  French  say, 
il  pisse  sur  ses  chaussures.  If  the  patient  lies  down  or  sits  for  any 
length  of  time  during  the  day,  micturition  is  more  difficult  than  if  he 
moves  about.  The  condition  of  patients  in  this  stage  of  the  disease 
is  not  uniform,  as  they  may  urinate  better  for  a  day  or  a  week,  or 
indeed  even  a  month,  than  they  could  for  corresponding  previous 
periods  of  time.  Anything  which  causes  congestion  of  the  pelvic 
organs  augments  the  symptoms. 

Thus  it  is  observed  that  the  patients  are  made  worse  by  severe  con- 
stipation, irregularities  in  eating  and  drinking,  sexual  excesses,  and 
particularly  by  exposure  to  wet  and  cold,  being  compelled  to  urinate 
more  frequently  and  to  make  greater  efforts  to  expel  the  urine  from 
the  bladder,  it  often  requiring  two  or  three  attempts  to  complete  its 
expulsion.  At  night  they  sometimes  suffer  from  persistent  erections. 
The  amount  of  urine  voided  during  the  night  is  greater  than  that 
passed  during  the  day,  constituting  a  nocturnal  polyuria.  If  a 
catheter  be  passed  after  micturition  the  bladder  will  be  found  empty. 
Thus  there  is  no  residual  urine,  a  fact  which  is  characteristic  of  this 
stage  of  the  disease. 

The  process  may  continue  this  way  for  many  years,  until  it  finally 
leads  to  the  development  of  partial  retention,  the  symptoms  remaining 
the  same  as  above  described,  with  the  exception  that  they  become 
a  little  more  troublesome.  The  frequency  of  micturition  is  increased, 
the  patients  being  obliged  to  arise  from  three  to  eight  times  a  night 
to  make  water.  It  is  impossible  for  them  to  urinate  in  the  recumbent 
position.  The  nocturnal  polyuria  is  augmented  and  the  pain  caused 
by  the  resistance  of  the  obstruction  to  vesical  contractions  becomes 
more  severe.  The  periods  of  freedom  from  difficulty  which  occur 
during  the  first  stage  become  shorter,  until  at  last  the  bad  days  con- 
stitute the  greater   part  of  the  year. 

The  general  health  begins  to  suffer,  the  patients  are  deprived  of 
sleep  by  frequent  urination,  and  gradually  become  emaciated,  although 
their  condition  is  decidedly  different  from  the  true  cachexia  which 
accompanies  malignant  prostatic  tumors.  These  two  conditions  are 
also  to  be  differentiated  by  the  fact  that  in  the  case  of  prostatic  hyper- 


338  DISEASES    OF    THE    PROSTATE    GLAND. 

trophy  improvement  takes  place  if  a  period  of  rest  and  amelioration  of 
the  local  trouble  can  be  obtained,  while  true  cachexia  always  becomes 
progressively  worse. 

If  a  person  in  this  stage  of  the  disease  be  catheterized  immediately 
after  he  has  urinated,  more  or  less  residual  urine  will  be  found  in  the 
bladder.  The  amount  varies  from  50  to  200  cc.  [1  §  to  6§  ounces].  Occa- 
sionally even  more  remains,  although  the  patient  can  still  void  a  goodly 
portion.  It  is,  however,  very  noticeable  that  the  individual  quantities 
of  urine  which  the  patient  passes  are  considerably  less  than  the  normal. 

This  stage  of  incomplete  and  partial  retention  may  likewise  con- 
tinue for  years,  extending  even  beyond  a  decade,  without  any  especial 
episodes  occurring.  The  greater  the  quantity  of  urine  remaining  in 
the  bladder,  the  greater  the  pressure  upon  the  vesical  wall,  and  con- 
sequently the  greater  the  distention  of  the  bladder;  as  this  distention 
increases  the  power  of  the  bladder  to  contract  and  empty  itself  becomes 
more  and  more  impaired.  It  finally  comes  to  pass  that  the  bladder 
is  converted  into  a  large  sac,  in  which  an  enormous  quantity  of  urine 
is  retained  after  each  and  every  act  of  micturition. 

With  the  establishment  of  this  condition  the  third  stage  soon 
becomes  fully  developed.  Incomplete  retention  is  generally  super- 
seded by  complete  retention,  the  patient  being  unable  to  void  any  urine 
except  when  the  accumulation  reaches  above  the  level  of  the  sphincter. 
Even  under  these  circumstances  micturition  must  be  effectuated  by 
the  help  of  abdominal  pressure.  The  patient  squats,  bends  forward, 
or,  in  short,  assumes  any  position  in  which  he  finds  he  can  eject  a  few 
cubic  centimeters  of  urine. 

The  distention  of  such  bladders  is  often  enormous.  I  have  known 
them  to  hold  2  to  3  liters  [approximately  2  to  3  quarts].  Strange  as  it 
may  seem  the  patients  are  frequently  not  much  inconvenienced  by 
this  condition.  Although  the  abdomen  is  filled  by  the  distended  blad- 
der, which  reaches  above  the  umbilicus,  not  much  pain  is  experi- 
enced. As  the  bladder  is  filled  to  overflowing,  there  is  a  continual 
endeavor  to  expel  the  surplus  quantity,  and  hence  the  frequency 
of  micturition  is  much  increased.  The  general  health  has  already 
materially  deteriorated.  The  patient  has  become  feeble  and  emaciated, 
but  his  condition,  when  compared  with  the  serious  morbid  changes 
which  exist,  is  quite  tolerable.  This  is  especially  the  case  when  the 
urine  has  remained  clear,  that  is,  when  no  infection  of  the  bladder 
has  taken  place.     The  appetite  may  remain  good. 


HYPERTROPHY    OF    THE    PROSTATE.  339 

A  most  troublesome  complaint  is  the  involuntary  discharge  of  urine, 
which  has  been  erroneously  termed  incontinence.  As  soon  as  the 
bladder  is  so  over-filled  that  the  urine  rises  above  the  level  of  the 
sphincter  the  latter  is  separated  and  the  urethra  is  opened  like  a  funnel, 
with  the  result  that  the  urine  escapes.  Thompson  has  rightly  called 
this  condition  overflow  of  the  bladder.  Guyon  designates  it  as  the 
incontinence  of  overflow  {incontinence  par  regorgement).  The  pa- 
tients wet  themselves.  At  first  this  happens  only  at  night,  the  sphincter 
still  being  able  to  hold  back  the  urine  when  the  upright  posture  is 
maintained;  later,  however,  this  power  is  lost  and  the  patients  wet 
themselves  during  the  day.  When  this  state  is  reached  the  period 
of  freedom  from  infection  generally  terminates;  to  this  matter  we 
shall  soon  refer  again. 

The  course  of  the  disease  is  not  always  as  it  has  been  above  depicted. 
According  to  this  description  retention  of  urine  develops  gradually. 

As  often  at  least,  if  not  oftener,  acute  complete  retention  takes 
place  at  intervals.  Patients  who  have  been  voiding  urine  without 
difficulty  are  suddenly  seized  with  inability  to  pass  as  much  as  a  single 
drop.  Despite  the  greatest  efforts,  despite  the  auxiliary  force  of 
abdominal  pressure,  despite  every  conceivable  form  of  medication 
and  baths  the  bladder  remains  tightly  closed.  The  earlier  this  acute 
retention  occurs  the  more  serious  is  the  disturbance  it  produces,  for 
early  in  the  disease  the  bladder  is  not  distended  and  the  vesical  muscu- 
lature cannot  yield  to  the  pressure  exerted  by  the  urine.  Most  fright- 
ful vesical  spasms  occur  as  the  bladder  becomes  more  and  more  dis- 
tended; this  state,  in  fact,  is  as  painful  as  any  which  can  affect  mankind. 
The  sufferer  cannot  keep  still,  but  walks  the  floor  constantly,  trying 
by  every  possible  means  to  force  out  a  few  drops  of  urine.  These 
efforts  are  made  as  often  as  every  five  minutes,  but  they  usually  are 
productive  of  no  result.  If  assistance  is  not  obtained  and  the  disten- 
tion of  the  bladder  persists  for  any  considerable  time,  the  bladder 
is  violently  stretched  and  severe  and  usually  permanent  injury  is 
inflicted. 

The  development  of  this  acute  retention  of  urine  is  due  to  conges- 
tion, engorgement,  and  serous  infiltration  of  the  prostate  resulting 
from  obstruction  in  the  prostatic  vessels,  especially  in  the  periprostatic 
plexus.  All  the  circumstances  which  have  previously  been  mentioned 
as  being  liable  to  cause  exacerbation  of  the  symptoms  of  simple  pros- 
tatic hypertrophy  are  also  capable  of  inducing  complete  retention 


340  DISEASES    OF    THE    PROSTATE    GLAND. 

of  urine.  Therefore  it  occurs  in  both  the  first  and  second  stages  of 
the  disease;  in  the  third  stage  it  cannot  occur  for  the  reason  that  chronic 
retention  already  exists.  In  fact  it  is  the  rule  for  the  disease  to  begin 
with  such  a  retention,  or  for  retention  to  supervene  in  connection  with 
other  symptoms.  The  slight  symptoms  often  present  in  the  first  stage 
are  hardly  noticed  by  the  patient  until  a  sudden  retention  of  urine  drives 
him  to  the  surgeon.  The  malady,  of  course,  is  already  of  long  dura- 
tion, perhaps  having  existed  for  years.  I  have  arrived  at  this  conclusion 
from  clinical  observation,  as  the  result  of  which  I  think  it  may  be 
stated  that  the  disease  often  begins  before  the  fiftieth  year.  I  have 
observed  such  a  condition  in  the  beginning  of  the  fortieth  year,  and 
have  seen  it  develop  later  into  a  typical  prostatic  hypertrophy. 

That  the  development  of  retention  of  urine  is  due  to  congestion,  and 
not  to  sudden  growth  of  the  prostate,  is  shown  by  the  fact  that  it  subsides 
and  the  patients  are  again  able  to  urinate. 

Unfortunately,  however,  an  exact  prognosis  cannot  be  made.  I 
have  seen  cases  in  which,  after  a  single  attack  of  acute  retention,  the 
patients  never  regain  the  power  of  voluntary  micturition.  These 
cases,  however,  constitute  the  exception.  Usually  the  congestion 
subsides,  and  with  it  the  retention  gradually  disappears.  The  process 
of  resolution  may  occupy  days,  weeks,  or  even  months. 

In  the  gradually  progressive  chronic  retention  conditions  are  entirely 
different.  Here  a  permanent  mechanical  obstruction  exists,  either 
in  the  form  of  a  tumor  encroaching  upon  the  prostatic  urethra,  or  as  a 
third  lobe  which  obstructs  the  neck  of  the  bladder  like  a  valve.  It  is 
characteristic  of  the  latter  form  of  obstruction  that  the  more  the  patient 
strains  the  more  firmly  he  shuts  the  valve.  Efforts  to  urinate  then  are 
futile. 

Acute  retention  may  recur  frequently.  There  are  prostatics  in 
whom  the  slightest  departure  from  regular  habits  of  living,  or  the 
most  trivial  exposure  to  cold,  will  induce  an  attack  of  retention,  and 
again  there  are  others  who  go  for  years  before  a  second  attack  super- 
venes. I  have  also  known  persons  who  have  had  a  single  attack  of 
retention  and  then  have  remained  free  from  it  many  years.  It  fre- 
quently happens  that  acute  retention  ushers  in  a  period  of  chronic 
incomplete  retention;  in  other  words,  after  the  acute  complete  retention 
subsides  and  the  patients  regain  the  power  to  urinate  a  certain  quantity 
of  residual  urine  remains  in  the  bladder. 

The  effect  of  both  forms,  but  especially  that  due  to  chronic  retention 


HYPERTROPHY    OF    THE    PROSTATE.  34I 

of  long  duration,  is  felt  by  the  entire  organism.  The  first  manifesta- 
tion— provided  that  the  bladder  is  not  infected — occurs  in  the  form  of 
digestive  disturbances.  Guyon  has  very  appropriately  termed  these 
digestive  disturbances  dyspepsia  urinaria.  The  patients  lose  their 
appetite,  and  show  a  particular  disinclination  to  take  meat  and  heavy 
foods,  rather  preferring  liquids  to  solids.  This  may  be  due  to  dimi- 
nution of  the  power  of  the  kidneys  to  eliminate  waste  material  from 
the  blood,  their  function  being  impaired  by  the  engorgement  with  which 
they  are  affected.  As  a  result  of  this  renal  insufficiency  urinary  intoxi- 
cation is  produced,  and  it  in  turn  gives  rise  to  the  dyspeptic  symp- 
toms, which  are  sometimes  called  the  aseptic  cachexia  of  prostatics. 
It  differs  only  in  degree  from  the  anorexia  which  is  characteristic  after 
infection  has  taken  place  (septic  cachexia),  and  which  will  be  con- 
sidered in  connection  with  the  complication  of  hypertrophy  of  the 
prostate. 

The  most  frequent  complication  of  prostatic  hypertrophy  is  cystitis. 
It  occasionally  develops  in  the  first  stage  of  the  disease,  before  retention 
has  occurred,  and  it  almost  always  takes  place  during  the  stage  of 
partial  retention.  The  causes  have  been  fully  explained  in  the  article 
on  cystitis. 

In  cases  which  have  not  been  examined  or  treated  instrumentally 
it  must  be  assumed  that  the  infective  microorganisms  which  circulate 
in  the  blood,  or  which  gain  access  to  the  bladder  from  the  urethra  or 
rectum,  find  a  favorable  soil  prepared  for  them  by  the  prevailing 
engorgement  and  hyperemia. 

In  those  cases,  however,  in  which  catheterization  has  been  followed 
by  cystitis  it  is  probably  due  either  to  the  introduction  of  germs  from 
without,  or  to  infection  with  microorganisms  which  have  lain  dormant 
in  the  urethra,  but  which  become  virulent  as  a  result  of  the  engorge- 
ment affecting  the  bladder.  It  is  possible  to  catheterize  patients 
having  prostatic  hypertrophy  without  infecting  them,  provided  that 
sterile  instruments  and  a  sterile  lubricant  be  used  and  the  bladder 
afterwards  washed  out  with  a  1:1000  solution  of  silver  nitrate;  but 
if  the  catheterization  be  frequently  repeated,  as  it  inevitably  must  be 
in  cases  of  chronic  retention,  cystitis  is  wont  to  develop  despite  all 
precautions.  It  differs  little  from  the  previously  described  forms  of 
vesical  inflammation.  It  is  difficult  to  cure  because  of  the  residual 
urine,  but  yet  a  cure  is  often  effected.  The  classical  proof  for  the 
existence  of  cystitis  is  the  presence  of  pus  in  the  urine;  other  symptoms, 


342  DISEASES    OF    THE    PROSTATE    GLAND. 

such  as  urgency  of  urination  and  pain,  are  of  little  importance  because 
they  are  also  symptoms  of  prostatic  hypertrophy  and  generally  pre- 
exist. 

Of  less  importance  is  the  frequent  urethritis,  which  usually  is  caused 
by  irritation  incident  to  the  necessary  catheterization.  Prostatitis, 
on  the  other  hand,  requires  increased  attention  because  it  may  proceed 
to  suppuration,  and,  as  already  stated,  prostatic  abscess  in  an  hyper- 
trophied  prostate  offers  a  bad  prognosis. 

The  diagnosis  of  abscess  can  be  made  by  palpating  the  prostate 
through  the  rectum;  softened  areas  in  the  enlarged  gland  will  be 
detected.  Intermittent  or  remittent  fever  is  also  present.  In  two 
cases  in  which  the  abscess  ruptured  into  the  urethra  I  have  noticed 
that  the  urine,  which  was  very  turbid,  became  even  more  cloudy 
from  the  increased  admixture  of  pus.  In  other  cases  suppuration 
seemed  to  have  a  curative  effect,  as  urination  became  less  difficult. 
This  improvement  is  comparable  to  that  which  it  is  sought  to  obtain 
by  removing  the  prostate. 

Now  and  then  unilateral  or  bilateral  epididymitis  occurs.  It  is 
probably  due  to  the  extension  of  infection  from  the  urethra  to  the 
ejaculatory  ducts.  It  presents  no  peculiarities.  It  usually  pursues 
a  chronic  course,  although  it  often  shows  a  tendency  to  exacerbation; 
it  generally  terminates  in  induration,  rarely  in  suppuration. 

Vesical  calculi  are  not  uncommon  in  the  subjects  of  prostatic  hyper- 
trophy. They  are  mostly  secondary  phosphatic  stones.  Their 
development  is  due  to  the  vesical  catarrh  which  is  present,  the  mucus 
and  pus  forming  a  nucleus  around  which  the  salts  of  the  residual 
urine,  especially  the  phosphates  and  carbonates,  crystallize.  They 
are  observed  more  frequently,  therefore,  in  prostatics  with  neglected 
cystitis.  Occasionally  they  cause  trouble,  giving  the  patient  pain 
when  he  walks  or  exerts  himself,  and  also  producing  haemorrhage; 
they  may,  however,  give  rise  to  no  symptoms  whatever. 

It  is  characteristic  that  recurrences  soon  take  place  after  litholapaxy 
is  performed;  this  is  due  to  the  persistence  of  conditions  favorable 
to  stone-formation.  The  diagnosis  of  these  stones  is  not  always  easy. 
They  usually  lie  in  the  recess  behind  the  prostate,  which  is  not  accessible 
with  a  short-beaked  stone  sound;  therefore  they  often  cannot  be  felt. 
Cystoscopy  may  also  fail  to  detect  them  if  they  are  concealed  by  a 
projecting  lobe. 

Haemorrhages  occur  in  prostatics  irrespective  of  vesical  calculi. 


HYPERTROPHY    OF    THE    PROSTATE.  343 

They  may  be  exceedingly  profuse  and  uncontrollable.  They  occasion- 
ally follow  congestion  due  to  retention  of  urine.  The  bladder  becomes 
filled  with  blood-clots  which  are  too  large  to  be  voided  through  the 
urethra.  It  is  only  with  great  difficulty  that  the  thick  clots  can  be 
washed  out  through  a  catheter.  The  haemorrhages  may  last  for  days. 
They  generally  originate  in  the  bladder,  but  may  also  take  place 
from  the  kidneys. 

Of  special  importance  are  the  haemorrhages  which  follow  catheter- 
ization. It  is  obvious  that  severe  haemorrhage  may  result  from  injury 
— however  slight — of  the  spongy  vascular  tissue  of  the  prostate  and 
prostatic  urethra.  But  even  when  no  injury  has  been  inflicted  a 
violent  haemorrhage  often  follows  catheterization  for  the  relief  of 
retention.  This  is  haemorrhage  ex  vacuo.  It  is  due  to  sudden  removal 
of  the  high  pressure  to  which  the  bladder  has  been  subjected  by  the 
excess  of  urine.  The  result  is  that  the  relaxed  veins  suddenly  become 
filled,  and  if  they  be  atheromatous  they  may  rupture. 

A  complication  which  is  important,  because  it  is  severe  and  endan- 
gers life,  is  ascending  pyelonephritis.  It  is  well  known  that  vesical 
infection  frequently  does  not  extend  upwards.  In  performing  autop- 
sies upon  old  prostatics  who  had  had  vesical  infection  for  ten  years 
or  more  I  have  frequently  found  the  kidneys  to  be  perfectly  healthy, 
or  to  present  only  slight  changes,  such  as  are  produced  by  pressure- 
atrophy  or  mild  chronic  interstitial  nephritis.  In  other  cases,  however, 
the  infection  ascends,  being  particularly  favored  by  the  engorgement 
which  exists.  We  then  have  to  do  with  chronic  pyelitis,  pyelone- 
phritis and  pyonephrosis. 

These  are  also  the  cases  in  which  signs  of  general  infection  are 
usually  present.  It  manifests  itself  by  loss  of  strength.  The  patients 
become  miserable  and  cachectic.  Anorexia  is  marked,  intense  thirst 
is  complained  of,  and  the  tongue  becomes  coated  and  so  parched 
that  it  can  hardly  be  protruded  from  the  mouth.  If  this  cachexia 
increases  the  patients  die. 

It  must  be  stated,  however,  that  this  chronic  urinary  intoxication 
can  take  place  without  the  kidneys  being  involved,  resulting  entirely 
from  the  diseased  prostate  and  bladder.  In  the  latter  case  it  is  probably 
due  to  absorption  of  urinary  or  bacterial  toxins.  This  form  of  chronic 
urinary  intoxication,  or  urosepsis,  is  occasionally  associated  with 
mild  febrile  disturbances.  According  to  my  experience  it  is  more 
dangerous  than  acute  sepsis  occurring  through  the  urinary  passages. 


344 


DISEASES    OF    THE    PROSTATE    GLAND. 


The  organism  responds  to  acute  infection  with  a  chill  and  fever,  which 
seems  to  relieve  the  blood  of  poison,  inasmuch  as  the  patients  recover 
after  the  occurrence  of  one  or  more  of  these  phenomena.     On  the  other 


Fig.  186. — Enormous  hypertrophy  of  the  prostate.     The  catheter 
has  perforated  the  middle  lobe.     (Albarran.) 

hand,  I  have  seen  only  a  few  patients  recover  from  chronic  urinary 
sepsis. 

The  development  of  acute  as  well  as  chronic  sepsis  is  especially 
favored  by  injury  to  the  urethra  or  prostate.     When  catheterization 


HYI'KRTROl'IIY    OF    THE    PROSTATE. 


345 


is  difficult  false  passages  are  not  uncommonly  made.  Figure  186  shows 
a  very  good  picture  of  one.  The  catheter  has  been  forced  directly 
through  the  middle  lobe.  Figure  187  shows  a  constriction  of  the  pros- 
tatic urethra  caused  by  the  enlarged  prostate,  together  with  a  false 
passage,  the  course  of  which  is  marked  by  the  bougie.     Severe  bleeding 


Fig.  187. — Hypertrophy  of  the  prostate  with  narrowing 
of  the  prostatic  urethra.     (Albarran.)    • 


results,  which  makes  catheterization,  and  especially  emptying  of  the 
bladder,  more  difficult  than  it  formerly  was  because  of  the  large  clots 
which  are  formed.  In  robust  persons  acute  urinary  fever,  together 
with  chills,  generally  follows,  but,  as  a  rule,  the  patients  recover.  In 
the  weak,  who  can  no  longer  offer  resistance  to  the  invading  micro- 
organisms, chronic  urosepsis  develops  and  usually  causes  death. 


346  DISEASES    OF   THE    PROSTATE    GLAND. 

After  this  detailed  description  of  the  symptoms,  complications 
and  course  of  hypertrophy  of  the  prostate  it  may  be  said  that  the 
diagnosis  is  generally  not  difficult.  It  is  completed  and  perfected  by 
physical  examination,  consisting  in  palpation  of  the  prostate  through 
the  rectum,  catheterization,  and  cystoscopy. 

As  concerns  palpation,  it  is  practised  with  the  patient  in  the  knee- 
chest  position;  the  bladder  must  be  empty.  As  soon  as  the  finger 
passes  beyond  the  membranous  urethra  a  projecting  mass  will  be 
detected.  It  varies  greatly  in  size.  Its  lateral  and  superior  boundaries 
should  be  determined  if  possible;  the  superior  boundary,  however, 
can  often  not  be  defined,  because  the  prostate  may  attain  such  dimen- 
sions that  its  upper  edge  cannot  be  reached  by  a  finger  of  ordinary 
length. 

Furthermore,  information  should  be  sought  as  to  whether  the 
surface  of  the  gland  is  smooth  or  rough,  whether  the  gland  is  hard 
or  comparatively  soft,  whether  portions  of  it  are  softer  than  others, 
and  finally  whether  both  lobes  are  equally  hypertrophied  or  whether 
distinct  asymmetry  is  detectable. 

After  palpation  has  been  employed  examination  with  catheters 
should  be  undertaken.  The  object  of  this  examination  is  to  determine 
the  degree  of  retention  and  the  length  of  the  urethra.  The  determina- 
tion of  residual  urine  is  requisite  for  exact  diagnosis.  It  must  be  remem- 
bered, however,  that  conditions  vary.  The  true  amount  of  residual 
urine  can  be  ascertained  only  after  several  examinations  have  been  made 
at  long  intervals,  and  at  times  when  the  patient  is  free  from  attacks  of 
congestion.  The  length  of  the  urethra  may  be  considerably  increased; 
it  lias  already  been  stated  that  it  may  measure  as  much  as  30  cm. 
[12  inches]. 

In  connection  with  this  examination  the  capacity  of  the  bladder 
may  be  determined,  if  necessary,  by  slowly  injecting  it  with  sterile 
water.  The  urinary  conditions,  however,  will  often  show  its  degree 
of  distensibility. 

Cystoscopy  will  reveal  the  prostatic  enlargement.  {See  the  illus- 
trations accompanying  the  article  on  cystoscopy.)  The  projection  of 
the  enlarged  prostate  into  the  bladder  can  be  plainly  seen,  as  can  also 
the  narrow  channel  formed  by  the  convergence  of  the  right  and  left 
lobes  toward  the  median  line;  in  lesser  degrees  of  hypertrophy  the 
irregular  margin  of  the  sphincter  is  shown;  finally,  the  third  lobe  is 
distinctly  seen,  sometimes  jutting  into  the  bladder  like  the  cervix 


HYPERTROPHY    OF    THE    PROSTATE.  347 

uteri  into  the  vagina.  In  addition  the  state  of  the  bladder  may  be 
ascertained.  In  most  cases  typical  trabecular  and  diverticula  will  be 
recognized,  together  with  the  evidences  of  cystitis,  and  possibly  calculi 
may  be  seen  as  well.  Calculi  concealed  in  diverticula  should  be 
carefully  looked  for  as  they  readily  escape  notice  unless  special  atten- 
tion be  given  to  their  discovery. 

Although,  as  a  rule,  the  diagnosis  will  not  be  difficult,  there  are  three 
conditions  with  which  certain  cases  may  be  confounded:  these  are 
vesical  tumors,  malignant  tumors  of  the  prostate,  and  retention  of 
urine  occurring  irrespective  of  prosatic  enlargement. 

In  regard  to  vesical  tumors  it  may  be  said  that  the  clinical  symp- 
toms they  produce  are  very  different  from  those  of  prostatic  hyper- 
trophy. Rectal  palpation  also  shows  unequivocal  differences,  as 
tumors  infiltrating  the  vesical  wall- — and  these  are  the  only  ones  which 
enter  the  question — never  form  a  nodular  mass  projecting  into 
the  rectum.  Finally,  the  cystoscopic  picture  shows  differences.  Solid 
neoplasms  of  the  bladder,  which,  of  course,  are  the  only  ones  to  be 
considered,  are  seldom  so  regularly  formed  and  so  evenly  and  smoothly 
covered  with  mucous  membrane  as  are  prostatic  tumors.  The  latter 
are  also  situated  directly  at  the  sphincter,  with  which  they  are  con- 
tinuous, so  that  they  can  be  followed  by  the  cystoscope  if  it  be  turned 
on  its  axis. 

As  concerns  malignant  tumors  of  the  prostate  the  following  con- 
siderations will  afford  a  diagnosis:  prostatic  tumors  may  occur  in 
young  persons,  whereas  hypertrophy  seldom  taker>  place  before  the 
fiftieth  year;  tumors  cause  more  rapid  enlargement  of  the  gland  than 
does  hypertrophy,  and  produce  cachexia  sooner;  rectal  palpation 
reveals  the  irregularity  of  tumors,  which  are  almost  always  asymmet- 
rical and  give  off  processes  to  one  side  or  the  other.  These  projections 
are  usually  external,  in  the  direction  of  the  seminal  vesicles,  or  lateral, 
along  the  wall  of  the  pelvis.  The  consistency  of  tumors,  too,  is  much 
harder.  Finally,  the  occurrence  of  metastases  offers  a  means  of 
differentiation.  They  are  invariably  present  in  cases  of  malignant 
prostatic  growths,  occurring  mostly  in  the  inguinal  region,  where  they 
are  readily  palpable.  They  give  rise  to  neuralgic  pains  in  the  lower 
extremities,  which  are  not  experienced  in  prostatic  hypertrophy.  Cys- 
toscopically  the  two  conditions  can  often  not  be  distinguished  one 
from  the  other. 

Urinary  retention  without  prostatic  hypertrophy,  for  example, 


348  DISEASES    OF   THE    PROSTATE    GLAND. 

that  due  to  paralysis  of  the  bladder,  or  fibrous  degeneration  of  the 
vesical  wall  resulting  from  arteriosclerosis,  is  readily  differentiated 
from  hypertrophy  by  rectal  palpation,  and  especially  by  the  shortness 
of  the  urethra.  The  history  of  the  case  and  the  clinical  findings  are 
also  of  help. 

The  prognosis  of  prostatic  hypertrophy  as  to  cure  is  absolutely 
bad.  Of  more  importance,  however,  is  the  prognosis  as  to  life.  In 
this  latter  respect  it  may  be  said  that  with  proper  care  and  treatment 
the  subjects  of  prostatic  hypertrophy  may  live  comfortably  for  years 
or  tens  of  years  and  attain  an  advanced  age.  On  the  other  hand, 
frequent  attacks  of  retention  of  urine,  difficulty  of  catheterization, 
and  complications,  especially  infection  of  the  upper  urinary  passages, 
make  the  prognosis  worse. 

Those  patients  do  best  whose  bladder  undergoes  adequate  com- 
pensatory dilatation.  When  this  takes  place  the  bladder  is  converted 
into  a  large  reservoir  which  can  receive  and  hold  the  urine  for  twelve 
to  eighteen  hours  without  causing  the  patient  inconvenience  and 
without  exerting  any  deleterious  influence  on  other  organs  of  the 
body.  The  prognosis  is  much  less  favorable  for  those  patients  whose 
bladder  is  small  or  contracted  (concentric  hypertrophy).  The  uncon- 
trollable strangury  reduces  their  strength  and  lessens  their  power 
of  resistance. 

The  most  dangerous  complication,  urosepsis  and  uraemia,  occurs 
'much  more  readily  in  these  patients  than  in  those  of  the  first-named 
group.  Frequently  recurring  haemorrhages  also  make  the  prognosis 
more  unfavorable.  The  worst  cases  of  all  are  those  in  which  there 
are  great  obstacles  to  catheterization,  so  that  in  case  of  retention  of 
urine  the  danger  of  creating  false  passages  and  thereby  causing 
infection  becomes  especially  great. 

TREATMENT. 

The  treatment  of  prostatic  hypertrophy  is  a  difficult  task.  It  requires 
great  knowledge  and  much  patience  on  the  part  of  the  surgeon.  In 
view  of  the  fact  that  there  are  many  men  with  an  enlarged  prostate 
who  remain  free  from  trouble  as  long  as  they  five,  our  efforts  must  be 
directed  to  guarding  the  patient  against  those  injurious  influences 
which  are  known  to  produce  such  unfavorable  conditions  as  congestion 
and   engorgement   of   the   prostate.     Consequently   exposure  to  cold, 


HYPERTROPHY    OF    THE    PROSTATE.  349 

especially  of  the  feet,  alcoholic  excesses,  protracted  sitting,  fatiguing 
walks,  horseback  riding,  and  holding  the  urine  too  long  must  be  for- 
bidden. A  light  diet,  attention  to  digestion,  avoidance  of  spices,  and 
regular  exercise  are  to  be  enjoined.  It  is  important  that  the  bowels 
be  kept  regular. 

Apart  from  these  prophylactic  measures  treatment  may  be  instituted 
either  for  the  relief  of  symptoms  or  for  the  purpose  of  decreasing  the 
size  of  the  prostate.  Many  prostatics  can  get  along  for  years  with- 
out any  treatment,  a  careful  regimen  of  living  according  to  the  principles 
above  outlined  preserving  them  from  trouble  and  enabling  them  to 
attain  a  vigorous  old  age. 

If,  in  course  of  years,  occasional  attacks  of  severe  strangury,  pain, 
and  difficult  micturition  occur,  hot  baths,  especially  sitz-baths  at  a 
temperature  of  350  C.  [950  F.]  increased  to  420  C.  [107  F.],  and  hot 
applications  to  the  hypogastric  region  and  perineum,  together  with  the 
use  of  morphine  or  heroin  suppositories,  or  an  injection  containing 
these  drugs  with  antipyrin  0.5  [7J  grains]  or  pyramidon  0.3  [5  grains], 
may  be  employed  with  advantage.  These  measures  in  association 
with  confinement  of  the  patient  to  bed  or  to  his  room  usually  promptly 
ovecome  the  congestive  attacks. 

The  principal  symptomatic  treatment  is  catheterization.  It  is 
self-evident  that  it  must  be  employed  in  cases  of  chronic  or  acute  com- 
plete retention  of  urine.  In  incomplete  retention,  too,  it  is  also  our 
chief  recourse.  As  catheterization  is  especially  difficult  in  the  subjects 
of  prostatic  hypertrophy,  and  as  it  is  also  not  without  danger,  the 
greatest  precaution  is  necessary  in  its  performance;  it  should  not  be 
employed,  moreover,  unless  it  is  strongly  indicated.  It  scarcely  need 
be  mentioned  that  the  strictest  asepsis  must  be  practised. 

First,  in  regard  to  the  technic  of  catheterization,  great  stress  must 
be  placed  upon  the  selection  of  proper  instruments.  In  general 
nothing  but  soft  instruments  (Nekton's  catheters)  should  be  used.  If 
these  cannot  be  made  to  pass  then  Mercier's  or  Guyon's  may  be  tried. 

If  the  introduction  of  these  soft  instruments  cannot  be  effected 
the  following  expedient  should  be  tried.  Both  anterior  and  posterior 
urethra  are  cocainized  with  about  6  cc.  [i£  drachms]  of  2  per  cent 
cocain  solution;  it  is  injected  with  an  ordinary  male  syringe  and  pressed 
backward  into  the  deep  urethra;  or  a  1  or  ^  per  cent  solution  may  be 
instilled  with  Guyon's  or  Ultzmann's  capillary  catheter. 

Adrenalin  is  also  worthy  of  trial,  as  it  produces  even  greater  anaemia 


350  DISEASES    OF    THE    PROSTATE    GLAND. 

than  cocain,  and  thus  may  cause  shrinking  of  the  tumescent  prostatic 
urethra.  The  injection  of  5  to  15  cc.  [1  to  4  drachms]  of  warm  sterile 
oil  is  also  often  useful,  as  it  lubricates  the  parts  and  frequently  permits 
the  passage  of  a  Nelaton  catheter  which  previously  could  not  be  intro- 
duced. 

If  all  attempts  with  soft-rubber  instruments  fail  silk-web  cathe- 
ters, provided  either  with  Mercier's  or  Guyon's  curve,  should  be  tried. 
In  introducing  these  instruments  care  should  be  taken  to  have  the 
angle  at  the  junction  of  the  shaft  and  beak  point  upwards.  The 
object  of  this  curve  is  to  have  the  point  glide  along  the  superior  [or 
anterior]  wall  of  the  urethra,  which,  as  is  well  known,  makes  the  least 
divergence.  These  silk-web  catheters  with  Mercier's  curve  are  the 
real  prostatic  catheters,  by  which  name  they  are  also  known. 

As  to  semi-hard  catheters  only  those  of  English  make  need  be  con- 
sidered. They  are  made  of  some  material  which  becomes  malleable 
when  heated  and  remains  firm  when  cold.  They  are  dipped  in  hot 
water,  bent  to  the  desired  curve,  and  allowed  to  cool.  There  is  no 
uniformity  of  opinion  in  regard  to  which  curve  is  the  best.  The  various 
curves  shown  in  the  accompanying  illustration,  reproduced  from  Socin's 
work,  represent  those  which  have  been  found  useful  by  different 
surgeons  (Fig.  188  ).  The  English  catheters  are  best  bent  to  the  curve 
shown  in  e.  During  its  introduction  the  catheter  becomes  warmed 
somewhat  and  its  excessive  curvature  yields  and  so  adapts  itself  to  the 
shape  of  the  urethra  that  the  bladder  can  be  entered  even  in  very  diffi- 
cult cases.  This  procedure,  devised  by  Sir  Henry  Thompson,  requires 
much  practice  and  great  skill. 

Guyon  practises  a  similar  procedure  with  a  catheter  coude,  which  he 
partly  but  not  entirely  draws  over  a  stylet  in  such  a  manner  as  to  con- 
vert it  into  a  bicoude,  or  double-elbowed  instrument  (see  Fig.  188  /). 

If  careful  and  not  unduly  protracted  efforts  with  soft  and  semi- 
hard instruments  result  in  failure,  then  metal  catheters  may  be  used, 
the  rule  being  to  employ  one  of  large  caliber  having  a  free  curve  and  a 
long  beak.  In  moderate  degrees  of  hypertrophy  catheters  bent  almost 
to  a  right  angle  and  having  a  moderately  long  beak  will  suffice.  Where 
excessive  enlargement  with  considerable  lengthening  of  the  urethra 
exists,  Sir  Benjamin  Brodie's  catheter  (e),  the  curve  of  which  corres- 
ponds to  the  arc  of  a  circle,  is  very  serviceable.  In  the  illustration 
the  catheter  is  overcurved.  In  reality  the  tip  should  end  2  cm.  [j-  of 
an  inch]  above  the  eye. 


HYPERTROPHY  OF  THE  PROSTATE. 


351 


Fig.  188. — Catheters  of  different  curves  used  in  hypertrophy  of  the  prostate. 


352 


DISEASES    OF    THE    PROSTATE    GLAND. 


Metal  catheters  should  be  slowly  and  cautiously  passed.  The 
buttocks  should  be  elevated.  A  finger  in  the  rectum  will  guide  the 
point  of  the  instrument  into  the  prostatic  urethra.  Force  must  never 
be  used,  but  the  instrument  must  rather  be  made  to  grope  its  way 
into  the  bladder.  Manifestly  theoretical  descriptions  will  not  be  of 
any  service.  Mastership  here  can  be  attained  only  by  practice.  A 
rule  to  be  borne  in  mind,  however,  is  that  the  employment  of  metal 
catheters  having  short  beaks  similar  to  that  of  the  stone-sound  is  abso- 
lutely inadmissible. 


Fig.  189. — Two  perforations  of  the  middle  lobe  of  a 
hypertrophied  prostate.     (Giiterbock.) 

With  such  short-beaked  instruments  there  is  great  danger  of  per- 
forating the  prostate  instead  of  passing  over  it.  Once  a  false  passage 
is  established  the  difficulty  of  catheterization  becomes  augmented, 
because  the  tip  of  the  catheter  will  always  have  a  tendency  to  enter  the 
false  passage.  Figure  189  gives  a  good  representation  of  how  a  catheter 
may  perforate  the  middle  lobe;  it  shows  two  perforations. 

The  great  danger  of  haemorrhage  and  infection  occasioned  by  a 
false  passage  has   already  been   described. 


HYPERTROPHY    OF    THE    PROSTATE  353 

Patients  having  false  passages  should  not  be  catheterized 
unless  some  urgent  indication  exists.  Such  indications  will  be 
stated  presently.  If  it  becomes  necessary  to  catheterize,  if,  for  ex- 
ample, retention  of  urine  develops,  then  a  large  metal  catheter  should 
be  tried  first,  its  beak,  if  possible,  being  carried  along  that  wall  of  the 
urethra  through  which  the  perforation  did  not  take  place. 

If  the  retention  is  relieved  by  this  procedure  and  does  not  recur 
it  will  not  be  necessary  to  catheterize  again.  If,  on  the  contrary,  the 
retention  continues,  the  difficulty  attending  the  introduction  of  the 
metal  catheter  will  always  be  experienced  anew.  For  this  reason  it  is 
advisable  to  leave  a  permanent  catheter  in  the  bladder  until  the  false 
passage  has  healed. 

Only  soft  instruments  are  adapted  for  permanent  catheterization. 
A  metal  catheter  should  never  be  left  in  the  bladder  over  night,  as  its 
point  may  perforate  the  wall  if  the  patient  moves  unduly  while  half 
asleep.  I  know  of  a  case  in  which  this  accident  happened.  A  Nelaton 
or  silk- web  catheter  with  or  without  a  curve  should  be  tried  first,  and 
if  it  cannot  be  passed  a  stylet  should  be  inserted  and  the  instrument 
bent  to  the  same  curve  possessed  by  the  previously  inserted  metal 
catheter.  After  the  wire  has  been  removed  the  catheter  is  fastened 
with  adhesive  plaster  or  a  bandage. 

The  self- retaining  catheters  devised  by  Pezzer,  Malecot,  and  myself 
are  excellent  for  permanent  catheterization  (Fig.  190).  Pezzer's 
instrument  expands  into  a  mushroom-like  tip,  Malecot's  has  two 
projections,  and  mine  four,  which,  during  the  introduction  of  the 
instrument,  lie  even  with  the  stylet,  but  expand  after  the  latteris  removed 
and  come  up  against  the  sphincter.  In  this  way  it  is  prevented  from 
slipping  out. 

As  to  the  indications  for  catheterization  it  is  obviously  indispensable 
in  cases  of  acute  and  chronic  complete  retention.  If  the  usual  means 
employed  in  acute  retention,  such  as  hot  baths,  hot  applications,  and 
injections  of  morphine  produce  no  result,  the  bladder  must  be  emptied 
by  catheterization. 

In  chronic  complete  retention,  too,  the  catheter  cannot  be  dispensed 
with.  The  small  quantity  of  urine  which  rises  above  the  level  of  the 
sphincter  and  escapes  spontaneously  is  not  sufficient  to  afford  relief. 
The  patients  have  continuous  strangury  which  can  be  relieved  only 
by  emptying  the  bladder.  Similar  to  these  are  the  cases  of  incomplete 
retention  in  which  a  large  quantity  of  urine  remains  in  the  bladder. 
23 


354 


DISEASES    OF    THE    PROSTATE    GLAND. 


In  all  these  cases  catheterization  is  necessary  to  empty  the  bladder. 
If  it  be  very  difficult  it  is  better  to  introduce  a  permanent  catheter 
and  thus  save  the  patient  the  suffering  incident  to  repeated  passages 
of  an  instrument. 


If  the  bladder  is  as  yet  uninfected  and  the  urine  obtained  is  clear, 
I  would  advise  the  use  of  the  permanent  catheter  only  in  exceptional 
cases,  because  it  is  almost  always  sure  to  lead  to  the  development  of 


HYPERTROPHY    OF    THE    PROSTATE.  355 

cystitis.  It  gives  rise  to  urethritis  which  extends  to  the  bladder; 
therefore  when  the  urine  is  clear  the  permanent  catheter  should  be 
employed  only  when  catheterization  is  very  difficult  and  associated 
with  haemorrhage. 

If  the  bladder  is  infected  then  no  hesitancy  need  be  felt  as  to  its 
use.  Care  should  be  taken,  however,  to  cleanse  the  bladder  once 
daily  with  silver  nitrate  i-iooo  and  thrice  daily  with  mercury  oxycya- 
nate  1-5000.  These  irrigations  also  serve  to  keep  the  catheter  from 
becoming  encrusted. 

(Although  it  was  formerly  the  custom  to  follow  Bazy's  recommenda- 
tion and  keep  the  subjects  of  permanent  catheterization  in  bed,  and, 
moreover,  to  continue  the  procedure  for  only  a  few  weeks  at  most, 
I  have  introduced  a  method  of  treatment  by  permanent  catheter- 
ization which  has  proved  to  be  very  valuable  in  a  number  of  cases. 
It  consists  in  allowing  the  catheter  to  remain  in  for  months,  or  indefi- 
nitely for  that  matter,  and  also  allowing  the  patients  to  walk  about  and 
follow  their  usual  vocation.  I  use  my  own  self- retaining  catheter, 
which  has  four  arches,  and  which  does  not  easily  become  encrusted. 
The  bladder  must  be  irrigated  once  or  twice  a  day,  and  the  catheter 
changed  every  month  or  at  least  every  two  months.  At  first  a  suppu- 
rative urethritis  is  produced,  but  it  soon  heals  and  the  urethra  becomes 
dry;  thus  the  natural  passage  is  converted  into  an  artificial  fistulous 
canal.  If  the  patient  experiences  much  difficulty  at  first  he  should 
be  kept  in  bed  and  given  morphine. 

This  treatment  possesses  the  great  advantage  of  doing  away  with  the 
necessity  of  confining  the  patients  to  bed,  and  thus  abolishes  the  danger 
of  hypostatic  pulmonary  congestion,  so  prone  to  develop  in  old,  decrepit 
persons  who  are  bed-ridden.  They  are  free  from  the  strangury  and 
pain  caused  by  each  passage  of  an  instrument,  and  urinate  easily 
every  hour  or  two,  according  to  their  needs,  by  simply  removing  the 
cork  which  closes  the  catheter. 

The  question  as  to  how  much  residual  urine  must  remain  in  the 
bladder  to  necessitate  this  form  of  permanent  catheterization,  or 
ordinary  catheterization,  can  be  easily  and  accurately  answered. 
It  depends  upon  the  size  of  the  bladder  and  the  properties  of  the  urine. 
It  may  be  said  that  the  dilatation  of  the  bladder,  which  increases  as 
the  quantity  of  residual  urine  becomes  greater,  represents  a  curative 
effort  on  the  part  of  nature.  Patients  with  well-marked  chronic 
retention  (2  or  3  liters  of  urine)  are  occasionally  met  with  who  suffer 


356  DISEASES    OF   THE    PROSTATE    GLAND. 

no  impairment  of  health,  only  they  have  to  urinate  more  frequently 
than  other  men. 

The  condition  of  patients  having  contracted  bladder  is  much  worse. 
While  the  urgency  of  micturition  experienced  by  the  first  class  sub- 
sides as  soon  as  they  are  catheterized  once  or  twice  daily,  the  tenesmus 
suffered  by  patients  with  small  bladders  is  uncontrollable.  The  in- 
dication for  catheterization,  therefore,  depends  upon  the  dispro- 
portion between  the  capacity  of  the  bladder  and  the  amount  of 
residual  urine. 

If  cystitis  complicates  chronic  retention  catheterization  almost 
always  works  favorably.  It  rarely  does  harm,  although  occasionally 
a  single  catheterization  may  prove  fatal.  I  have  had  two  deaths 
occur  immediately  after  simple  catheterization.  It  had  hardly  been 
begun  before  the  patients  became  worse,  while  previously  their  general 
condition  had  been  good.  The  tongue  became  dry  and  coated,  anorexia 
and  nausea  developed,  stupor  supervened,  and  death  took  place  within 
two  days.  As  cystitis  was  already  present  in  both  cases,  infection  as 
the  cause  can  be  excluded;  the  temperature  was  not  elevated;  no 
hasmorrhage  had  been  produced.  It  cannot  be  explained  otherwise 
than  by  assuming  that  the  difference  in  pressure  between  the  emptied 
and  previously  filled  bladder  resulted  in  such  a  profound  alteration 
of  the  organism  as  to  cause  the  exitus  of  the  feeble  and  atheromatous 
patients.  Therefore  it  should  be  an  established  rule  to  draw  off  the 
urine  cautiously  and  slowly  from  patients  who  have  not  been  catheter- 
ized before  and  whose  bladder  is  much  distended,  and  afterwards  to 
inject  100  cc.  [3^  ounces]  of  sterile  water  into  the  bladder.  In  time 
we  may  come  to  empty  the  bladder  completely  and  also  to  draw  off 
the  water  used  for  irrigation. 

The  severe  complications,  acute  and  chronic  urosepsis,  which 
may  follow  a  simple  catheterization  even  when  it  has  been  practised 
with  the  utmost  precaution,  have  already  been  mentioned.  They 
have  nothing  in  common  with  the  condition  just  described.  While 
in  robust  persons  infection  is  followed  by  chills  and  fever,  the  urine 
becoming  turbid  and  purulent,  in  the  old  and  decrepit  either  an  acute 
sepsis  develops,  which  soon  ends  in  death,  or  chronic  sepsis,  the  so- 
called  urinary  fever,  occurs;  this  latter  condition  runs  its  course 
with  only  slight  elevation  of  temperature.  The  patients  are  plainly 
on  the  decline;  their  nutrition  becomes  poorer  and  their  aversion  to 
food   more   and  more  noticeable.     Intense  thirst  is  the  predominant 


HYPERTROPHY    OF    THE    PROSTATE.  357 

symptom.  The  urine  is  purulent  and  does  not  become  clear  in 
response  to  irrigations.  The  patients  become  gradually  weaker  until 
death  occurs. 

This  chronic  urinary  intoxication  or  urinary  fever  is  difficult  to  combat. 
Naturally  recourse  will  be  had  to  the  internal  disinfectants,  of  which 
urotropin  holds  first  rank,  it  being  a  drug,  too,  which  should  always 
be  administered  as  a  prophylactic  to  those  who  have  entered  upon 
catheter-life.  Permanent  relief  for  the  bladder  should  be  secured 
by  regular  catheterization  or  by  the  use  of  a  self- retaining  catheter, 
and  the  bladder  should  be  cleansed  by  antiseptic  irrigations,  prefer- 
ably of  silver  nitrate.  In  extreme  cases  the  establishment  of  a  perineal 
fistula  will  be  resorted  to  in  order  to  afford  exit  for  the  urine  at  the 
deepest  part  of  the  bladder,  and  thus  prevent  further  absorption  of 
septic  material  by  permitting  the  urine  to  drain  away  as  soon  as  it  is 
discharged  from  the  ureters.  Cardiac  stimulants,  nourishment  supplied 
in  every  possible  way,  even  in  the  form  of  nutritive  enemata  if  necessary, 
a  liberal  quantity  of  alcohol,  and  periodic  saline  injections  or  hypo- 
dermoclysis  are  indicated.  By  these  measures  the  patients  can  fre- 
quently be  saved.  Anorexia,  thirst,  fever  and  general  weakness  slowly 
disappear,  and  the  patients  recover  to  the  extent  of  regaining  the  same 
degree  of  health  which  they  possessed  before  the  infection  occurred. 

The  treatment  of  acute  complete  retention  requires  special  consider- 
ation. There  are  many  obstacles  to  catheterization.  It  generally 
happens  that  the  surgeon  is  called  to  a  case  in  which  several  fruitless 
attempts  to  pass  an  instrument  have  already  been  made,  and  in  which 
false  passages  are  often  present.  In  such  cases  it  is  best  not  to  dilly- 
dally with  soft  catheters,  but,  after  cocainizing  the  urethra,  to  try  a 
large,  long-beaked  metal  instrument  having  a  pronounced  curve, 
and  if  this  will  not  pass  to  use  one  with  Brodie's  curve. 

No  hesitancy  need  be  felt  about  anesthetizing  the  patient,  for  he 
generally  is  in  such  a  state  of  excitement  and  restlessness  that  the 
catheter  cannot  be  passed  with  ease  and  caution.  If  catheterization 
does  not  succeed  after  a  reasonable  trial,  it  should  be  abandoned  and 
puncture  of  the  bladder  with  a  capillary  trocar  at  once  made. 
The  skin  is  incised  a  little  above  the  symphysis  and  the  trocar  plunged 
quickly  and  forcibly  downwards  and  backwards.  Capillary  puncture 
is  entirely  without  danger,  even  when  repeated.  I  have  practised  it 
six  times  on  the  same  patient  without  doing  him  any  harm.  The 
fine  puncture  agglutinates   at  once.     Injury  of  the   peritoneum  or 


358  DISEASES    OF    THE    PROSTATE    GLAND. 

bowel  is  out  of  the  question  because  of  the  high  position  of  the  peri- 
toneum. Moreover,  I  deem  it  more  conservative  to  puncture  the 
bladder  than  to  persist  in  efforts  at  catheterization,  especially  if  false 
passages  be  present.  If  puncture  be  performed  a  few  days  in  suc- 
cession and  the  urethra  left  undisturbed,  it  will  usually  be  found  that 
the  catheter  can  then  be  easily  passed. 

It  is  only  in  cases  of  severe  haemorrhage  into  the  bladder  that  capil- 
lary puncture  fails;  the  admixture  of  urine  and  blood  is  too  thick  to 
flow  through  the  fine  trocar,  which  may  also  be  occluded  by  clots.  In 
these  cases  of  violent  prostatic  haemorrhage  into  the  bladder,  supra- 
pubic section  must  be  contemplated  as  an  operation  of  necessity. 

Severe  haemorrhage  with  simultaneous  retention  of  urine  and  dilata- 
tion of  the  bladder  can  frequently  be  relieved  by  catheterization.  A 
large  catheter  is  introduced  and  a  small  quantity  of  sterile  water 
injected  through  it  at  high  pressure  as  soon  as  the  eye  becomes 
clogged  with  clots;  powerful  contractions  of  the  bladder  result  and 
the  clots  are  generally  expelled  with  the  urine.  This  manoeuvre  is 
repeated  until  as  many  clots  as  possible  are  removed.  If  need  be 
suction  may  be  made  with  a  good  syringe;  the  clots  are  thus  drawn 
into  the  syringe  and  the  urine  can  then  escape.  If  these  measures  do 
not  succeed  after  reasonable  trial  they  should  not  be  unduly  pro- 
longed; the  patients  become  weak  and  anaemic,  particularly  if  further 
bleeding  takes  place.  It  is  better  to  open  the  bladder  suprapubically, 
clear  out  the  clots,  and  tampon  the  bladder  firmly  with  sterile  gauze 
in  the  event  of  continued  haemorrhage. 

In  such  cases  the  bladder  has  been  punctured  with  Fleurant's 
large  trocar  and  a  catheter  introduced  through  the  wound  for  the 
purpose  of  emptying  the  bladder.  This  method  of  puncture  is  not 
suitable  for  these  cases  and  should  not  be  practised.  In  cases  where 
the  haemorrhage  is  severe  it  is  uncertain,  as  the  thick  clots  may  not  go 
through  the  trocar.  The  establishment  of  a  permanent  suprapubic 
fistula  is  not  advisable.  No  appliance  can  be  worn  which  will  close  it 
tightly;  the  patient  is  greatly  annoyed  by  always  being  more  or  less  wet. 
Moreover,  the  fistula  is  situated  much  too  high,  so  that  a  residuum 
of  urine  remains  in  the  bladder. 

The  peritoneum  has  been  injured  in  making  the  puncture,  and 
Frisch  mentions  a  case  reported  by  Monod  in  which  the  prostate 
itself  was  injured  to  such  an  extent  that  abundant  haemorrhage 
resulted. 


HYPERTROPHY    OF    THE    PROSTATE.  359 

This  procedure  is  justifiable  only  in  that  condition  which  I  have 
named  prostatismus,  a  condition  in  which  there  is  violent  and  uncon- 
trollable strangury,  although  little  or  no  residual  urine  is  present  in 
the  bladder.  In  most  cases  of  this  kind  the  bladder  is  somewhat 
diminished  in  size ;  if  its  cavity  be  very  much  lessened  the  case  is  to  be 
considered  as  one  of  contracted  bladder. 

In  both  these  classes  of  cases  little  is  to  be  expected  from  ordinary 
measures.  Contracted  bladders  cannot  be  influenced  by  any  kind 
of  treatment,  and  prostatismus  shows  obstinate  resistance.  Before 
an  artificial  canal  is  established  an  attempt  should  be  made  to  institute 
permanent  catheterization,  a  measure  which  possesses  the  additional 
advantage  of  draining  the  bladder  at  a  lower  level.  Unfortunately 
the  attempt  often  proves  futile  because  the  bladder  is  too  irritable 
to  tolerate  a  catheter.     Nevertheless,  it  should  always  be  tried. 

If  it  fails,  another  procedure  may  be  selected  for  the  prostatismus 
cases,  namely,  division  of  the  vas  deferens,  or  vasectomy,  which  will 
also  be  discussed  later  as  an  operation  for  the  radical  cure  of  hyper- 
trophy. This  operation  has  no  effect  upon  contraction  of  the  bladder, 
although  it  acts  very  well  in  prostatismus.  It  is  probable  that  the 
latter  condition  is  due  to  irritation  of  certain  nerves  which  is  pro- 
duced by  the  enlargement  of  the  prostate,  and  that  this  irritation  is 
abolished  by  section  of  the  vas  deferens  together  with  the  nerve  fila- 
ments which  accompany  it  to  the  prostate. 

Only  in  exceptionally  urgent  cases,  and  after  the  last  mentioned 
method  has  failed,  would  I  advise  the  establishment  of  a  suprapubic 
fistula,  and  even  then  I  think  cystotomy  and  the  use  of  Witzel's  canula 
preferable. 

In  1 90 1  Goldmann  proposed  the  operation  of  cystopexy  for  reten- 
tion of  urine  in  cases  in  which  vesical  distention  and  infection  has 
not  occurred.  In  this  operation  a  portion  of  the  anterior  vesical  wall 
not  covered  by  peritoneum  is  attached  as  high  up  as  possible  to  the 
anterior  abdominal  wall.  The  traction  thus  made  upon  the  anterior 
wall  of  the  bladder  is  said  to  bring  the  viscus  upwards  and  forwards 
and  prevent  the  formation  of  recesses  in  the  posterior  wall.  It  is  also 
supposed  to  draw  the  lips  of  the  internal  meatus  apart.  Goldmann 
has  obtained  good  results  in  several  cases  in  which  he  did  this  oper- 
ation. He  had  the  opportunity  of  making  an  autopsy  on  one  patient 
who  died  of  myocarditis  a  number  of  years,  after  the  operation  was 
performed.     The  following  conditions  were  revealed: 


360  DISEASES    OF    TELE   PROSTATE    GLAND. 

1.  A  broad  adhesion  between  the  bladder  and  the  anterior  abdomi- 
nal wall. 

2.  Anteversion  of  the  bladder. 

3.  Widening  of  the  internal  urethral  orifice. 

4.  No  signs  of  recesses  in  the  posterior  wall  of  the  bladder. 

5.  No  signs  of  dilatation  of  the  ureters  and  pelvis  of  the  kidneys. 
Unfortunately  this  operation  is  too  new  for  its  exact  value  to  be 

stated. 

All  the  procedures  which  we  have  mentioned  thus  far  come  under 
the  scope  of  symptomatic  treatment.  We  now  have  to  consider 
radical  treatment,  the  object  of  which  is  to  reduce  the  size  of  the 
prostate,  or  even  remove  it  completely,  and  thus  by  radical  means 
take  away  the  hindrance  to  micturition. 

A  series  of  procedures  formerly  recommended  and  practised  need 
only  be  mentioned,  because  they  have  proved  to  be  worthless,  and 
therefore  have  merely  historical  interest. 

There  are  no  internal  remedies  which  can  diminish  the  size  of  the 
prostate.  Prostaden,  which  was  recently  recommended,  proved  to 
be  merely  a  fashionable  nostrum.  Organotherapy  also  was  in 
vogue  at  one  time,  and  dried  prostatic  substance  was  fed  to  patients. 
The  results  were  absolutely  negative. 

Massage  of  the  prostate  for  the  purpose  of  reducing  hypertrophy 
has  been  abandoned  as  ineffective.  The  same  may  be  said  of  electric 
massage  and  electrolysis.  The  latter  undoubtedly  causes  the  gland 
to  become  slightly  smaller,  for  it  certainly  destroys  small  portions  of 
tissue ;  the  effect,  however,  is  only  slight,  and  the  number  of  treatments 
necessary  to  bring  about  any  considerable  diminution  in  size  so  great 
that   the   method   has   never  become   established. 

Compression  of  the  prostate  by  large  sounds  and  catheters  is  without 
effect ;  it  does  not  cause  atrophy  and  it  is  doubtful  whether  it  enlarges 
the  caliber  of  the  urethra. 

I  tried  the  X-ray  treatment  recommended  by  Moskowitz  in  1905, 
in  three  cases,  but  as  the  results  were  entirely  negative  I  made  no 
further  experiments  with  it. 

The  injection  into  the  prostate  of  fluids  which  cause  destruction 
of  tissue  and  subsequent  contraction,  such  as  solutions  of  iodine  and 
arsenic  (Iversen),  has  been  abandoned  as  too  dangerous.  The  danger 
of  suppuration  within  the  capsule  of  the  prostate,  with  consequent 
thrombosis,  is  too  great. 


HYPERTROPHY  OF  THE  PROSTATE.  36 1 

It  thus  came  to  pass  that  all  operative  procedures  for  the  cure  of 
hypertrophy  of  the  prostate  were  discontinued  until  within  the  last 
few  years,  during  which  time  a  complete  reversal  of  opinion  has  taken 
place,  and  three  kinds  of  operations  have  been  devised  one  after 
another,  and  each  has  been  declared  to  possess  superior  merits. 

We  will  first  mention  Bier's  operation,  which  consists  in  the  ligation 
of  both  internal  iliac  arteries.  Bier  believes  that  the  prostate 
can  be  made  to  atrophy  by  ligaturing  these  vessels,  which  supply  it 
with-  blood,  just  as  myoma  of  the  uterus  atrophies  after  the  uterine 
arteries  have  been  tied.  Aside  from  the  fact  that  the  cases  reported 
by  Bier  do  not  prove  the  good  results  of  the  operation,  for  the  reason 
that  they  were  mostly  cases  of  comparatively  recent  retention  of 
urine,  which  not  uncommonly  undergo  spontaneous  relief  and  therefore 
cannot  be  taken  as  criteria,  the  procedure  is  much  too  formidable 
and  dangerous  to  be  practised  on  old  and  enfeebled  persons.  With 
few  exceptions  (Willy  Meyer)  it  has  found  no  supporters. 

Treatment  took  an  entirely  new  course  with  the  introduction  of 
the  so-called  sexual  operations,  which  were  devised  almost  at  the 
same  time,  in  the  years  1893  and  1894,  by  Ramm,  of  Christiana,  and 
White,  of  Philadelphia.  These  surgeons  recommended  double 
castration,  their  theory  being  based  on  observations  which  had 
convinced  them  that  the  prostate  ceased  to  grow  in  young  animals 
which  had  been  castrated,  that  in  older  ones  it  atrophied,  and  that 
the  analogous  condition  of  uterine  myoma  diminished  in  size  after 
removal  of  the  ovaries. 

The  smallness  of  the  gland  in  eunuchs  and  in  the  subjects  of  anor- 
chism  and  cryptorchidism  was  adduced  as  proof  of  the  correctness 
of  their  theory. 

Except  as  to  the  comparison  of  prostatic  hypertrophy  with  uterine 
myoma,  which  is  not  apposite  to  the  subject,  for  the  reason  that  the 
prostate  is  an  organ  which  cannot  be  compared  to  the  uterus,  the  result 
of  the  experiments  is  correct.  I  have  myself  conducted  a  large  number 
of  similar  experiments  upon  dogs  and  rabbits,  and  have  found  that 
the  glandular  portion  of  the  prostate  of  these  animals  atrophies  after 
the  performance  of  double  castration.  The  accompanying  illustrations 
fully  elucidate  the  change  which  ensues   (Figs.   191   and   192). 

Although  shrinking  actually  takes  place,  the  theoretical  conclusion 
drawn  from  this  fact  is  erroneous.  It  is  the  glandular  elements  of 
the  enlarged  prostate  which  shrivel;  but  it  has  been  definitely  deter- 


362 


DISEASES    OF    THE    PROSTATE    GLAND. 


mined  that  only  the  minority  of  cases  of  prostatic  hypertrophy  depend 
upon  hyperplasia  and  hypertrophy  of  these  elements.  In  the  majority 
of  cases  there  is  a  typical  nodular  myoma,  and  it  cannot  be  affected 
by  castration.     Thus  it  is  seen  that  castration  will  result  in  shrinkage 


Fig.  191. — Section  from  the  prostate  of  an  old  rabbit,     a  gland-lobules,  b  cysts,  c  stroma. 
d  stratified  bodies,  e  prostatic  vesicles,  /  seminal  vesicle,  g  urethra,  h  musculature. 


of  the  gland  in  only  the  few  cases  which  are  of  true  adenomatous  over- 
growth. 

The  results  of  practical  experience,  both  my  own  and  that  of  others, 
is  in  accord  with  these  deductions.  I  have  performed  castration 
for  prostatic  hypertrophy  about  twenty  times.  At  first,  influenced 
by  the  reports  of  others,  there  was  a  tendency  to  attribute  some  value 
to  the  procedure,  but  upon  more  candid  judgment  it  has  been  found 


HYPERTROPHY    OF    THE    PROSTATE. 


363 


to  be  without  practical  value;  indeed,  it  may  be  declared  to  be  injurious, 
as  it  exerts  an  unfavorable  influence  upon  the  patient's  mind.  It  is 
an  operation  which  has  been  abandoned. 

A  little  more  favorable  statements  may  be  made  in  regard  to  division 
of  the  vasa  deferentia.  Theoretically  its  effect  upon  the  prostate 
is  even  less  valuable  than  that  of  castration,  for  it  has  been  shown  that 
neither  the  testicles  nor  the  prostate  regularly  atrophy  after  its  per- 
formance.    (See  Figs.  193    and   194.)     In  some  instances  shrinkage 


'  (3.) 


2&.  ^\ 

("vA._.„.-- 


Fig.  192. — Section  from  the  prostate  of  an  old  rabbit  3J  months  after  castration. 
a  stratified  body  in  an  atrophied  gland-tubule,  b  collapsed  and  contracted  tubule, 
c  fibrous  stroma,  d  prostatic  vesicle,  e  urethra,  /  seminal  vesicle. 


took  place;  in  others  it  did  not  occur.  In  order  to  prevent  the  vasa 
deferentia  from  growing  together  again  Isnardi  excised  a  portion;  the 
result,  however,  remained  the  same. 

The  results  obtained  in  practice  correspond  to  those  given  by  exper- 
imentation. Vasectomy  has  no  effect  upon  the  size  of  the  prostate. 
Notwithstanding  this,  however,  it  has  acted  beneficially  in  a  few  cases, 
and  for  this  reason  I  would  not  exclude  it  from  the  treatment  of  pros- 
tatic hypertrophy.  Primarily  it  is  important  to  bear  in  mind  that 
the  procedure  is  entirely  harmless,  and  that  it  can  be  done  under 


364 


DISEASES    OF    THE    PROSTATE    GLAND. 


Schleich's  local  anaesthesia  in  a  very  short  time.  I  have  done  the 
operation  in  this  manner  twenty  times  and  allowed  the  patients  to 
go  home  at  once.  They  suffered  no  inconvenience  and  the  wounds 
healed  by  first  intention. 

The  operation  is  of  value  in  two  kinds  of  cases,  namely,  those  in 
which  epididymitis  develops  as  the  result  of  repeated  catheterization, 
and,  secondly,  in  prostatismus,  which  has  already  been  described. 
The  frequently  recurring  and  painful  epididymitis  is  permanently 
cured.  In  prostatismus,  in  which  increased  desire  to  urinate  is  pre- 
sent without  material  contraction  of  the  bladder  and  without  residual 
urine,  the  favorable  results  have  to  be  attributed  to  something  else 


Connective  tissue  stroma. 
Musculature  of  the  stroma. 


Large  septum. 


Smooth  glandu- 
lar wall. 


Small  septa. 


Papillary  excrescences. 
Fig.  193. — Prostate  of  a  full-grown  dog.     (Glandular  tubules.     Highly  magnified.) 


than  diminution  in  the  size  of  the  prostate.  We  are  led  to  this  con- 
clusion by  the  fact  that  the  benefit  often  ensues  within  a  few  days  after 
the  operation,  a  period  of  time,  of  course,  in  which  the  prostate  could 
not  have  undergone  contraction.  It  must,  therefore,  be  taken  for 
granted  that  the  division  of  the  nerves  which  accompany  the  vasa 
deferentia  to  their  entrance  into  the  prostate  relieves  the  irritation. 
It  is  only  for  these  two  classes  of  cases  that  vasectomy  can  be  recom- 
mended. 

Division  of  the  entire  spermatic  cord,  as  well  as  the  injection  of 
zinc  chloride  into  the  parenchyma  of  the  testes,  both  of  which  have 


HYPERTROPHY  OF  THE  PROSTATE. 


365 


been  advised,  are  to  be  condemned  because  they  are  liable  to  produce 
gangrene  of  the  testicles. 

In  recent  times  there  has  been  a  return  to,  and  an  attempt  to  improve, 
the  more  formidable  operations  which  had  formerly  been  tried  in  a 
few  cases.  These  operations  are  complete  and  partial  prostatec- 
tomy. Partial  or  total  removal  of  the  prostate  has  been  attempted 
through  a  suprapubic  cystotomy  incision,  through  a  perineal  opening, 
and  also  by  the  prerectal  route. 


Musculature  of  the  stroma. 


Connective  tissue  stroma. 


\  ^c;s/« 


Contracted  ducts ; 
lumen  obliterated 
and  recognizable 
only  by  the  stained  nuclei. 

Fig.  194. — Prostate  of  a  full-grown  dog  4J  months  after  double 
vasectomy.     (Highly  magnified.) 

To  trace  the  evolution  of  prostatic  surgery  would,  indeed,  be  interest- 
ing, but  in  a  work  of  this  character  space  will  not  permit  it  to  be  followed 
from  its  origin  to  its  present  stage  of  development.  Therefore  only 
the  most  important  epochs  will  be  mentioned. 

In  regard  to  suprapubic  prostatectomy  the  first  noteworthy  pro- 
cedure was  that  practised  by  Belfield,  of  Chicago,  and  McGill, 
of  Leeds.  These  surgeons  did  a  partial  prostatectomy  through 
suprapubic   and  transvesical  incisions,  opening  the  bladder,  incising 


366  DISEASES    OF    THE    PROSTATE    GLAND. 

the  mucous  membrane  over  the  prostate  and  then  removing  the  ob- 
structing portions  of  the  gland  by  cutting  them  away  or  enucleating 
them  with  the  fingers.  This  operation,  though  generally  known  as 
McGill's,  had  been  performed  three  times  by  Belfield  before  McGill 
operated  on  his  first  patient. 

I  practised  this  procedure  in  several  cases;  in  some  the  results  were 
gratifying,  in  others  the  patients  died,  and  so  I  came  to  consider  it 
too  severe  for  the  majority  of  prostatics. 

As  surgeons  gained  experience  with  this  operation  the  idea  of  enu- 
cleating the  prostate  in  its  entirety  was  conceived  and  executed.  Accord- 
ingly, in  1895,  Dr.  Eugene  Fuller,  of  New  York,  did  a  complete  enuclea- 
tion of  the  gland  in  one  piece  through  a  suprapubic  and  transvesical 
incision,  and  then  drained  the  bladder  through  a  perineal  opening. 

A  similar  enucleation  was  also  performed  in  1897  by  Dr.  F.  S. 
Watson,  of  Boston. 

In  1900,  Mr.  P.  J.  Freyer,  of  London,  adopting  and  modifying  the 
principle  of  Fuller's  method,  began  the  series  of  operations  which 
have  connected  his  name  with  suprapubic  prostatectomy.  He  has 
found  it  possible  to  enucleate  the  prostate  in  its  entirety  in  almost 
every  instance,  and  has  shown  that  perineal  drainage  is  not  necessary. 
The  perineal  operations  as  first  practised  were  partial  prostatec- 
tomies, the  obstructing  portions  of  the  gland  being  removed  through 
a  median  perineal  incision.  This  method  has  been  largely  practised  by 
Goodfellow,  of  San  Francisco,  who  finally  came  to  do  a  complete 
enucleation  through  this  incision. 

In  order  to  gain  better  access  to  the  gland  and  facilitate  its  complete 
removal  various  other  incisions  have  been  devised.  Chief  among 
these  may  be  mentioned  the  transverse  curved  incision  advocated 
by  Proust  and  Albarran  and  the  inverted  V  incision  of  Young. 

These  operations  are  to  be  welcomed  as  a  decided  advance  in  the 
therapy  of  prostatic  hypertrophy,  inasmuch  as  they  afford  relief  in  a 
class  of  cases  not  otherwise  amenable  to  treatment.  They  are  not 
without  danger,  however,  and  therefore  should  not  be  employed 
indiscriminately  nor  undertaken  lightly,  being  reserved  for  those 
cases  in  which  milder  measures  prove  futile. 

When  catheterization  fails  or  has  to  be  frequently  repeated  owing  to 
smallness  of  the  bladder  produced  by  thickening  of  its  walls,  when  it  is 
very  painful  or  is  followed  by  haemorrhage,  when  severe  cystitis  is 
present  or  frequent  attacks  of  retention  occur,  and  when  a  case  is  not 


,      HYPERTROPHY    OF    THE    PROSTATE.  367 

suitable  for  the  Bottini  operation,  then  a  radical  operation  is  to  be 
considered. 

The  one  selected  will  depend  upon  the  nature  of  the  individual 
case.  No  doubt  further  experience  will  result  in  better  knowledge  of 
the  exact  indications  for  the  two  recognized  procedures,  namely,  the 
suprapubic  and  perineal  operations.  At  present  the  weight  of  evidence 
seems  to  be  in  favor  of  the  former  for  the  majority  of  cases.  The 
functional  results  are  better,  the  complications  less  frequent,  and  a 
decided  decrease  in  mortality  has  occurred  as  improvements  in  opera- 
tive technic  have  taken  place.  In  my  clinic  it  has  been  the  operation 
of  choice.  It  is  easier  to  perform  than  perineal  prostatectomy,  and  as 
it  affords  a  better  view  of  the  field  of  operation  than  the  latter  method, 
it  enables  the  operator  more  surely  to  enucleate  the  gland  in  its 
entirety.  Moreover,  when  operating  through  the  suprapubic  route 
the  surgeon  is  not  at  all  liable  to  leave  calculi  in  the  retroprostatic 
pouch.  The  great  disadvantage  of  the  operation  is  the  poor  drainage 
which  it  affords.  In  order  to  overcome  this  disadvantage  external 
perineal  urethrotomy  has  been  performed  and  the  bladder  drained 
through  the  perineal  wound.  I  have  never  done  this  myself,  being 
satisfied  to  drain  through  the  suprapubic  wound  by  means  of  a  large 
rubber  tube. 

Among  the  unpleasant  sequelae  of  the  operation,  the  first  to  be 
mentioned  is  haemorrhage.  As  the  field  of  operation  is  easily  acces- 
sible, bleeding  can  almost  always  be  controlled  (see  under  Technic 
of  the  Operation).  Infection  must  also  be  taken  into  account,  as  it  is 
liable  to  occur  owing  to  the  action  of  the  septic  urine  upon  the  wound. 
Fistulae  sometimes  persist,  but  they  are  not  so  frequent  as  after  the 
perineal  operation,  in  which  injury  to  the  rectum  is  very  liable  to 
lead  to  the  formation  of  urethro -rectal  and  vesico-rectal  fistulae. 
Incontinence  of  urine  sometimes  ihough  rarely  occurs.  In  my 
clinic  it  is  exceedingly  uncommon.  Of  twelve  patents  operated  on 
in  the  Jewish  Infirmary,  however,  two  suffered  from  a  slight  degree 
of  incontinence. 

The  mortality  of  the  suprapubic  operation  still  remains  higher  than 
that  of  the  perineal.  Thus  Tenney  and  Chase  collected  396  cases  of 
suprapubic  prostatectomy,  with  a  mortality  of  9.8  per  cent  and  617  cases 
of  perineal  prostatectomy  with  a  mortality  of  7.6percent.  These  statis- 
tics are  based  upon  the  work  of  many  operators  and  not  upon  series 
of  cases  reported  by  surgeons  especially  skillful  in  the  performance  of 


368  DISEASES    OF    THE    PROSTATE    GLAND. 

the  respective  operations.  Therefore  they  may  be  considered  as  repre- 
senting a  fair  average  mortality-rate  of  the  two  procedures  up  to  the 
year  1906.  Freyer's  last  published  statistics  (1908),  based  upon  481 
cases,  give  a  mortality  of  6.65  per  cent  for  the  suprapubic  operation. 
Young's  latest  published  statistics  (1908),  based  upon  238  cases,  give 
a  mortality  of  2.9  per  cent  for  the  perineal  operation.  These  latter 
statistics  are  very  significant,  representing  as  they  do  the  mortality- 
rate  of  two  surgeons  who  have  had  unusual  experience  in  the  per- 
formance of  the  respective  operations.  Owing  to  improvements  in 
technic  there  has  been  a  constant  decrease  in  mortality,  and  in  all 
probability  this  decrease  will  continue.  In  1900  Fuller  stated  that  the 
mortality  after  suprapubic  prostatectomy  was  from  15  per  cent  to 
18  per  cent;  in  1904  Watson  gave  it  as  11  per  cent;  in  1905  Freyer's 
statistics  showed  it  to  be  9  per  cent,  and,  as  already  stated,  in  1908  he 
had  reduced  it  to  6.65  per  cent. 

Notwithstanding  its  higher  mortality,  I  consider  it  the  preferable 
operation  for  the  majority  of  cases.  If  the  prostate  is  entirely 
removed  and  the  patient  recovers  from  the  operation,  he  will  be 
completely  and  permanently  cured  of  his  trouble. 

It  would  be  difficult  to  define  the  exact  contraindications  to  this 
operation  because  improvements  in  its  technic  will  render  it 
applicable  to  a  greater  and  greater  number  of  cases.  It  is  very 
important  that  the  patient's  nutrition  be  not  reduced  too  low.  Ad- 
vanced atheroma,  severe  bilateral  renal  disease  and  other  serious 
organic  diseases  must  be  looked  upon  as  contraindications.  Uni- 
lateral pyelitis  and  cystitis,  however,  are  not  contraindications.  A 
large  number  of  my  patients  had  a  very  bad  cystitis,  which  disap- 
peared after  the  operation.  Even  when  these  contraindications  do 
not  exist,  the  operation  is  by  no  means  a  trivial  one.  A  patient  of 
mine,  aged  fifty-nine  years,  who  showed  no  signs  of  cardiac  or  arterial 
disease,  succumbed  to  shock  on  the  fourth  day  after  the  operation. 

The  technic  of  the  modern  operation  of  suprapubic  prostatectomy 
is  as  follows :  After  the  bladder  has  been  thoroughly  washed  out  with 
hot  saline  or  boric  acid  solution  and  about  four  ounces  of  the  fluid 
left  in  the  viscus,  the  soft  rubber  catheter  through  which  the  irriga- 
tion has  been  done  is  clamped  and  left  in  situ,  the  patient  put  into 
the  Trendelenburg  position,  and  the  bladder  exposed  by  a  suprapubic 
incision  from  two  to  five  inches  in  length,  according  as  the  patient  is 
thin  or  very  obese.     The  lower  end  of  this  incision  should  come  directly 


PLATE  II. 


24 


PLATE  III. 


PLATE  IV. 


a)    c 

o   § 


PLATE  V. 


,xl   c 


HYPERTROPHY    OF    THE    PROSTATE.  369 

against  the  symphysis  pubis.  When  the  bladder  is  brought  into  view 
two  retention  sutures  are  passed  through  its  outer  coats,  one  on  either 
side  of  the  line  through  which  it  is  to  be  opened;  or  the  viscus  may  be 
steadied  with  a  tenaculum  while  the  incision  is  being  made  and  also  until 
the  prostate  is  reached.  (Plate  II.)  The  catheter  acts  as  a  guide 
to  the  urethral  orifice  and  lobes  of  the  prostate.  When  the  gland  is 
located  the  mucous  membrane  covering  one  lobe  is  incised,  the  finger 
introduced  and  enucleation  begun.  (Plate  III.)  With  one  or  two 
fingers  of  the  other  hand  in  the  patient's  rectum  the  prostate  is  pushed 
up  toward  the  enucleating  finger.  (Plate  IV.)  In  some  instances 
the  finger  may  be  passed  across  to  the  second  lobe  and  the  latter  re- 
moved through  the  original  incision  in  the  mucous  membrane.  In 
others  the  membrane  over  the  second  lobe  will  have  to  be  incised.  As 
a  rule,  the  prostatic  urethra  and  ejaculatory  ducts  will  be  divided. 
Deaver,  from  whom  this  description  of  the  operation  has  chiefly  been 
taken,  states  that  he  considers  it  impossible  to  preserve  the  attachments 
of  the  ducts.  After  the  enucleation  has  been  completed  the  cavity 
formed  by  removal  of  the  prostate  is  irrigated  with  hot  saline  solution, 
and  if  haemorrhage  persists,  is  packed  with  gauze  and  the  vesical 
mucous  membrane  forming  its  roof  sutured  over  the  gauze.  One 
end  is  left  long  and  brought  out  through  the  suprapubic  wound  so  as 
to  facilitate  its  removal  (Deaver)  (Plate  V). 

Drainage  is  provided  by  a  long  rubber  tube  passed  into  the  bladder 
and  connected  with  a  bottle  or  jar  containing  an  antiseptic  fluid.  A 
sterile  gauze  dressing  is  cut  so  as  to  fit  around  this  tube,  which  is  held 
in  place  by  a  stitch  through  the  skin.  It  is  left  in  the  bladder  from 
two  to  six  days. 

The  bladder  should  be  irrigated  regularly,  at  first  through  the  supra- 
pubic wound,  later  through  the  urethra. 

In  regard  to  the  perineal  operation  it  may  be  stated  that  in  cases 
in  which  the  gland  is  hard  and  fibrous,  and  does  not  project  upward 
into  the  bladder  for  any  distance,  it  may  probably  be  better  removed 
by  this  method  than  by  the  suprapubic. 

The  technic  of  the  operation  is  practised  by  Hugh  Young,  who 
is  one  of  its  strongest  advocates,  is  as  follows:  The  patient  is  placed 
in  the  exaggerated  lithotomy  position  and  an  inverted  V-shaped 
incision  (Plate  VI),  each  branch  of  which  is  about  two  inches  long, 
is  made  through  the  superficial  structures  of  the  perineum.  The 
deep  tissues,  except  the  central  tendon  and  the  recto-urethral  muscle, 


3/0  DISEASES    OF    THE    PROSTATE    GLAND. 

are  divided  by  blunt  dissection.  The  membranous  urethra  is  then 
opened  on  a  grooved  staff,  its  edges  drawn  apart  with  forceps  or 
sutures,  and  the  prostatic  tractor  (Fig.  195)  introduced  and  opened. 
(Plate  VI.)  By  making  traction  with  this  instrument  the  gland  is 
drawn  into  the  wound.  When  it  has  been  brought  well  into  view  an 
incision  is  made  through  each  lateral  lobe  parallel  with  and  as  deep 
as  the  urethra.  (Plate  VII.)  The  capsule  of  the  gland  is  then 
separated  by  blunt  dissection  and  the  urethra  is  also  isolated  in  the 
same  manner.     Deep  enucleation  is  accomplished  with  the  finger. 

"  If  a  medium  lobe  or  bar  is  present,  it  can  generally  be  removed 
by  engaging  it  with  one  blade  of  the  tractor,  making  traction  and 
rotating  at  the  same  time.  This  will  generally  cause  the  lobe  to  pre- 
sent in  the  left  lateral  cavity  (Plate  VIII),  where  it  can  be  engaged 


Fig.  195. — Young's  prostatic  tractor. 


with  the  small  lobe-forceps,  or,  if  it  is  too  small  for  these,  by  some 
small  toothed  forceps,  and  enucleated  or  cut  away  with  scissors. 

"If  it  is  too  small  to  be  engaged  with  the  blade  of  the  tractor,  this 
instrument  may  be  removed  and  the  index-finger  of  the  left  hand 
inserted  through  the  dilated  urethra  and  used  as  a  tractor,  as  shown 
in  Plate  IX." 

In  this  operation  a  bridge  of  tissue  containing  the  urethra  and 
ejaculatory  ducts  is  preserved.  Occasionally,  however,  a  fibrous 
median  lobe  is  present  which  cannot  be  removed  by  forcing  it  into 
one  of  the  lateral  cavities  with  a  blade  of  the  tractor,  and  then  it  is  neces- 
sary to  cut  through  the  capsule  covering  the  ducts  and  destroy  them  in 
the  removal  of  the  obstruction.  The  lateral  cavities  are  packed  with 
gauze,  a  double  catheter  inserted  into  the  bladder  and  fastened  to 
the  skin-wound  by  a  suture  and  continuous  irrigation  begun.  The 
divided  ends  of  the  levator  ani  muscles  are  united  with  a  catgut  suture. 
The  drain  is  removed  on  the  second  day. 


PLATE  VI. 


Fig.  i. — The  inverted  V  cutaneous  incision.     (Young.) 


Fig.  2. — Opening  of  urethra  on  sound,  preparatory  to  intro- 
duction of  tractor.     (Young.) 


PLATE  VII. 


Tractor  introduced,  blades  separated,  traction  made  exposing  posterior 
surface  of  prostate.  Incisions  in  capsule  on  each  side  of  ejaculatory 
ducts.     (Young.) 


PLATE  VIII. 


m  , .  Bn  . 


w, 


\l 


Showing  technique  of  delivery  of  middle  lobe  into  cavity  of  left  lateral 
lobe.     (Young.) 


PLATE  IX 


Showing  use  of  finger  instead  of  tractor  to  draw  down  small 
median  lobe  into  lateral  cavity.     (Young.) 


25 


HYPERTROPHY    OF    THE    PROSTATE.  371 

Dr.  Young  has  had  good  results  from  this  operation  in  a  large  number 
of  cases,  his  last  published  report  being  based  upon  238. 

In  regard  to  the  mortality  of  the  perineal  operation,  the  statistics  of 
Proust,  based  upon  a  collection  of  813  cases,  show  a  mortality  of  7.63 
per  cent,  which  is  somewhat  higher  than  that  based  upon  smaller 
series  of  recent  cases. 

For  example,  in  322  cases  collected  by  Deaver  the  mortality  was 
6.83  per  cent,  and  in  1192  cases  collected  by  Tuffier,  6.6  per  cent. 
Young's  total  mortality  in  238  cases  is  only  2.9  per  cent. 

Among  the  sequelae  of  the  perineal  operation  may  be  mentioned 
perineal  and  rectal  fistulae,  incontinence  of  urine,  epididymitis,  impo- 
tence and  contraction  of  the  neck  of  the  bladder.  In  410  cases  studied 
by  Escat  perineal  or  rectal  fistulae  were  present  in  over  8  per  cent 
and  permanent  incontinence  in  over  3  per  cent. 

Young  believes  that  urethro-rectal  fistulae  are  due  to  a  breaking 
down  of  the  rectum  resulting  from  the  absence  of  support  normally 
afforded  by  the  levator  ani  muscles.  It  is  for  this  reason  that  he 
unites  the -divided  ends  of  the  muscles  with  a  heavy  catgut  suture 
when  the  operation  is  completed.  When  this  suture  is  tied  it  brings 
the  muscles  together  in  front  of  the  rectum,  thus  affording  support 
against  pressure  of  gauze  as  well  as  the  straining  which  takes  place  at 
stool. 

The  prostate  has  also  been  attacked  by  the  combined  suprapubic 
and  perineal  routes.  Thus  Nicoll  opens  the  bladder,  incises  the 
perineum  down  to  the  prostate,  and  then  pushes  the  gland  into  the 
perineal  wound  by  pressure  exerted  upon  it  through  the  bladder.  He 
does  not  open  the  urethra. 

Samuel  Alexander  performs  suprapubic  cystotomy,  opens  the 
urethra  on  a  grooved  staff  from  the  bulb  to  the  apex  of  the  prostate, 
pushes  the  gland  down  into  the  wound  through  the  bladder,  enucleates 
it,  and  then  introduces  both  a  suprapubic  and  perineal  tube.  The 
former  is  removed  on  the  fourth  day,  the  latter  on  the  seventh.  The 
bladder  is  irrigated  daily. 

Finally  we  come  to  a  consideration  of  the  Bottini  operation,  with 
reports  of  which  medical  literature  has  been  flooded  during  the  last 
ten  years.  In  1874  Bottini  published  his  method  of  galvano-caustic 
incision  of  the  prostate,  and  later,  at  various  medical  congresses, 
reported  and  lauded  the  results  he  obtained,  without,  however,  suc- 
ceeding in  awakening  any  interest  in  the  operation. 


372 


DISEASES    OF    THE    PROSTATE    GLAND. 


Freudenburg,  who  improved  the  instruments  used  in 
this  procedure,  was  the  first  to  attract  serious  attention 
to  it,  and  since  his  time  it  has  been  tried  and  studied 
everywhere. 

The  operation  is  really  a  modification  of  the  old 
Merrier  and  Civiale  operations,  which  consisted  in  cutting 
out  a  piece  of  the  prostate.  Bottini  sought  to  accomplish 
the  same  result  with  the  galvano- caustic  incisor  and  at 
the  same  time  lessen  the  danger  of  haemorrhage. 

The  construction  of  the  instrument  is  shown  in  Fig. 
1 96.  The  platino-iridium  blade,  which  is  concealed  in 
the  shaft  during  the  introduction  of  the  instrument,  is 
brought  out  of  the  beak  by  turning  a  screw  at  the  handle, 
in  a  manner  similar  to  that  in  which  the  male  blade  of  a 
lithotrite  is  withdrawn  from  the  female  blade.  The  plati- 
num blade  is  heated  by  a  strong  battery;  a  current  of 
cold  water  flows  between  the  blade  and  the  shaft  to 
keep  the  latter  from  becoming  hot. 

The  technic  of  the  operation  is  very  simple.  It  can  be 
done  under  local  anaesthesia,  but  I  advise  the  use  of  a 
general  anaesthetic  because  I  consider  thorough  burning 
advantageous,  and  this  is  poorly  borne  when  only  local 
anaesthesia  is  employed.  The  bladder  is  emptied  and 
then  partly  distended  with  air  [or  fluid] ;  the  instrument 
is  then  passed  into  the  bladder  the  same  as  a  metal 
catheter,  the  beak  turned  downwards  and  laterally  and 
brought  firmly  against  the  projecting  prostate.  The  best 
place  to  make  the  incision  has  been  previously  deter- 
mined by  cystoscopic  examination. 

The  knife  should  be  white-hot.  The  tissues  should 
be  burned  slowly,  ten  minutes  being  consumed  for  each 
cut;  one  incision  is  made  downward  and  to  the  right,  one 
downward  and  to  the  left,  and  one  directly  downward; 
an  upward  incision  should  never  be  made.  The  cut 
must  not  be  too  long.  As  a  rule,  3  cm.  [1 1  inches]  will 
suffice. 

A  finger  should  be  placed  in  the  rectum  and  the  tip  of 
the  instrument  sought  for  behind  the  prostate.  The  instrument  must 
be  held  close  against  the  prostate,  which  is  best  done  by  keeping  the 


Fig.  196. 
Bottini's  pros 
tatic  incisor. 


HYPERTROPHY    OF    THE    PROSTATE.  373 

handle  somewhat  elevated ;  it  must  also  be  kept  fixed  so  that  the  beak 
will  not  slip  into  the  urethra.  A  catheter  is  introduced  and  fastened 
in  place  after  the  operation  if  complete  or  serious  incomplete  retention 
has  previously  existed. 

The  important  questions  which  arise  concerning  this  operation  are, 
first,  what  results  are  obtained  by  it;  second,  what  are  its  dangers;  third, 
should  it  be  employed,  and  if  so  in  what  cases.  These  questions  have 
been  answered  differently  by  different  surgeons.  At  first  surgeons  were 
generally  enthusiastic  over  it.  The  results  were  apparently  brilliant. 
Gradually,  however,  more  and  more  bad  results  followed  its  employ- 
ment, so  that  its  value  finally  came  to  be  judged  more  calmly.  I 
withheld  my  opinion  six  years  so  that  I  might  be  able  to  speak  from 
experience.  As  I  have  now  performed  the  operation  thirty  times, 
and  as  it  is  a  comparatively  new  procedure,  in  regard  to  which  personal 
experience  counts  for  considerable,  I  will  express  solely  my  own 
personal  views  concerning  it. 

If  we  adhere  to  the  above  mentioned  classification  of  cases  into 
those  associated  with  retention  and  those  of  prostatismus  without 
residual  urine,  it  is  plain  that  the  operation  is  suitable  only  for  those 
of  the  first  class.  Three  cases  of  prostatismus  which  I  operated  on 
were  made  worse,  the  painful  urgency  of  urination  being  increased 
instead  of  diminished.  From  the  day  of  operation  until  six,  nine, 
and  eighteen  months  afterward,  respectively,  more  severe  pain  was 
experienced  than  had  ever  been  present  before.  It  was  felt  in  the 
penis  and  also  in  the  rectum. 

These  observations  are  entirely  in  accord  with  the  theoretical 
considerations.  Although  the  prostate  is  enlarged  in  prostatismus, 
no  obstruction  great  enough  to  prevent  the  patient  emptying  his 
bladder  is  present.  It  is  self-evident,  moreover,  that  the  burning  of 
one  or  more  grooves  in  the  enlarged  prostate  will  increase  the  nervous 
irritability  upon  which  the  condition  largely  depends.  Therefore, 
in  these  cases  the  Bottini  operation  is  contraindicated. 

As  to  its  employment  for  cases  of  retention,  either  partial  or  com- 
plete, those  which  are  chronic  are  the  only  ones  which  need  be  con- 
sidered. Acute  retention  of  urine  [due  to  hypertrophy  of  the  prostate] 
never  requires  operative  interference,  because  it  can  be  made  to  yield 
to  regular  catheterization.  If  it  has  persisted  longer  than  three  months, 
then,  according  to  my  experience  at  least,  the  question  of  operation 
arises. 


374  DISEASES    OF    THE    PROSTATE    GLAND. 

Some  of  these  chronic  cases  were  entirely  cured  by  the  Bottini 
operation.  The  residual  urine  and  pain  disappeared  and  micturition 
was  reduced  to  normal  frequency.  These  were  all  cases  in  which  the 
urethra  was  lengthened,  a  circumstance  which  shows  that  the  principal 
trouble  lay  in  the  urethra. 

Many  patients  also  were  improved.  It  is  true  that  they  did  not 
empty  the  bladder  completely  after  the  operation,  but  they  voided 
better  than  they  could  before.  The  stream  of  urine  was  more  free  and 
the  pain  disappeared  or  became  considerably  lessened. 

In  a  few  instances  the  first  operation  was  fruitless,  although  after 
the  second,  the  patients,  who  had  not  voided  a  drop  of  water  for  years, 
began  to  urinate  again,  and  were  able  to  empty  or  nearly  empty  their 
bladder.  In  other  cases  absolutely  no  result  was  observed.  This 
latter  class  included  both  complete  and  incomplete  retention.  Patients 
with  complete  retention  could  not  void  after  the  operation,  and  those 
with  incomplete  retention  continued  to  have  the  same  quantity  of 
residual  urine.  In  some  cases,  too,  a  second  operation  was  likewise 
ineffective. 

I  have  four  deaths  to  report.  Only  three  of  these  were  directly  due 
to  the  operation,  one  patient  having  succumbed  to  heart  failure.  He 
was  a  decrepit  man  of  seventy-five,  with  advanced  arteriosclerosis, 
in  whom  catheterism  produced  intense  suffering.  On  account  of  this 
pain  I  decided  upon  operation,  which  was  performed  in  the  usual 
manner.  The  patient  became  weaker  day  by  day.  His  temperature 
remained  normal;  the  pulse  was  small;  nothing  abnormal  could  be 
found  in  the  abdomen  and  rectum.  Four  days  after  operation  he 
died  of  heart  failure. 

The  second  death  resulted  from  haemorrhage.  At  first  the  oper- 
ation seemed  to  have  been  successful.  No  bleeding  occurred.  On 
the  third  day  a  sudden  and  inexplicable  haemorrhage  occurred,  which 
was  so  violent  that  it  occluded  the  catheter  with  clots.  With  difficulty 
the  catheter  was  kept  free.  At  the  expiration  of  four  days  the  bleeding 
ceased,  but  in  the  meantime  the  patient  had  become  so  weak  and 
anaemic  that  he  died  on  the  eighth  day  after  operation. 

The  third  patient  was  killed  by  sepsis  resulting  from  phlegmonous 
inflammation  of  the  cut  surface  in  the  prostate.  He  was  old  and 
feeble  and  suffered  with  complete  retention  of  urine;  catheterization 
was  difficult.  The  prostate,  especially  the  middle  lobe,  was  of  immense 
size    (Fig.    197);    the   bladder   was    much  inflamed  and  filled  with 


HYPERTROPHY  OF  THE  PROSTATE. 


375 


purulent  ammoniacal  urine,  and  the  pelvis  of  both  kidneys  was  filled 
with  pus. 

The  fourth  death  was  also  due  to  sepsis.  In  this  case  the  bladder 
was  punctured  for  the  purpose  of  introducing  the  cystoscope  so  that 
the  incision  made  by  the  Bottini  knife  could  be  seen  and  guided.  This 
method  was  recommended  by  Hurry  Fenwick,  of  London,  and  Kraskc, 
of  Freiburg.     Autopsy  revealed  an  abscess  in  the  pelvic  connective 


Middle  lobe. 

Beginning  of  in- 
cision in  mid- 
dle lobe. 


Phlegmonous  ulcer- 
ation extending 
into  membranous 
urethra. 


Fig.  197. — Very  large  hypertrophied  prostate  operated  on  by  Bottini's  method. 


tissue.  The  Bottini  incision  was  covered  with  a  healthy  eschar  and 
there  was  no  evidence  of  inflammation  or  suppuration  around  it. 
This  fatality,  therefore,  is  to  be  attributed  to  the  vesical  puncture  rather 
than  to  the  Bottini  operation. 

If,  after  these  statements,  we  come  to  define  the  indications  for 
the  Bottini  operation,  the  following  considerations  are  in  place. 

When  an  operation  is  recommended  for  the  relief  of  a  condition 
in  which  vital  indications  for  its  performance  are  not  present,  it  is 


376  DISEASES    OF    THE    PROSTATE    GLAND. 

for  the  reason  that  non-operative  measures  are  ineffectual,  or  because 
it  is  feared  that  the  condition  will  become  worse  and  more  difficult 
of  control  if  allowed  to  progress  without  interference. 

Such  operative  interference  is,  of  course,  justifiable  only  when  it 
offers  at  least  a  reasonable  chance  of  improvement,  or  when  it  does 
not  entail  too  great  danger  to  life.  What  relation,  now,  does  this 
question  bear  to  hypertrophy  of  the  prostate,  and  particularly  as 
concerns  its  treatment  by  the  Bottini  operation? 

First  of  all  the  fact  must  be  borne  in  mind  that  many  prostatics 
having  chronic  retention  of  urine  enjoy  the  best  of  health  and  attain 
an  advanced  age.  The  state  of  their  health  depends  upon  the  capacity 
of  their  bladder.  Transitory  exacerbations  can  always  be  overcome 
and  thus  do  not  enter  the  question.  If  the  bladder  is  capacious, 
holding  from  \  to  i  liter  [i  to  2  pints],  the  patients  usually  do  not 
need  to  be  catheterized  more  than  twice  a  day,  or  they  may  catheterize 
themselves.  By  this  means  the  bladder  is  fully  relieved,  and  the 
patients  are  disturbed  neither  during  the  day  nor  at  night. 

Such  patients  naturally  have  no  desire  to  submit  to  operation, 
and  the  surgeon  surely  cannot  do  otherwise  than  approve  their,  atti- 
tude, especially  when  they  have  enough  spare  time  to  practise  catheter- 
ization with  the  utmost  care  and  caution,  thereby  obviating  the  danger 
incident  to  this  procedure. 

To  recommend  operation  to  them  because  there  is  a  possibility  of 
their  condition  becoming  worse  would  be  inadvisable  for  two  reasons. 
In  the  first  place  many  of  my  patients  have  reached  or  passed  the  age 
of  eighty  on  catheterism  with  entire  comfort  so  far  as  the  urinary  tract 
is  concerned;  it  cannot  be  asserted  that  these  case's  of  chronic  retention 
will  progress  to  the  bad,  and  on  the  other  hand,  it  cannot  be  affirmed 
that  they  may  not  become  worse  after  a  Bottini  operation.  It  can  no 
more  be  expected  that  partial  cauterization  of  the  prostate  will  arrest 
the  formation  of  new  tissue  than  it  can  be  assumed  that  fibro-my- 
omatous  or  adenomatous  overgrowth  will  not  progress  and  cause 
enlargement  of  the  gland  when  left  undisturbed.  Accordingly  no 
change  for  the  worse  may  take  place  when  operation  is  not  done, 
while  it  may  occur  after  operation  has  been  done.  Therefore,  in  this 
class  of  cases,  operation  should  not  be  advised. 

It  is  different  when  the  bladder  is  small,  or  when  catheterization  is 
very  difficult.  In  the  first  instance,  because  of  the  patient's  inability 
to  empty  his  bladder,  the  catheter  has  to  be  used  from  six  to  ten  times 


HYPERTROPHY    OF    THE    PROSTATE.  377 

in  twenty-four  hours,  or  even  oftener.  This  is  a  great  discomfort, 
causing  irritation  of  the  urethra  and  increasing  the  danger  of  infection. 
If  it  is  difficult  to  insert  the  catheter,  or  if  exacerbations  take  place 
which  make  its  insertion  impossible  without  repeated  trials,  then  life 
becomes  wretched,  and  we  are  warranted  in  concurring  with  the 
patient's  wish  to  be  freed  from  catheter-life. 

Operation  is  also  indicated  in  those  patients  who  are  subject  to 
frequent  attacks  of  acute  retention  of  urine.  The  more  frequently 
retention  develops  the  more  certain  is  the  patient  to  acquire  cystitis. 
As  is  well  known,  too,  nothing  predisposes  to  infection  more  than  the 
reduction  in  pressure  which  takes  place  after  the  bladder  is  freed  from 
complete  retention.  These  attacks  can  often  be  lessened  by  careful 
living,  attention  to  diet,  keeping  the  bowels  free,  and  avoiding  excesses, 
but  there  are  cases  in  which  the  congestion  of  the  prostate  is  so  great  that 
the  attacks  of  retention  frequently  recur.  The  more  difficult  catheter- 
ization is,  the  stronger  is  the  indication  for  operation  in  these  cases. 

The  dangers  of  the  operation  constitute  its  chief  contraindications. 
I  learned  from  my  own  cases  that  haemorrhage  and  sepsis  have  to  be 
taken  into  account.* 

If  the  patients  are  very  feeble,  affected  with  arteriosclerosis,  and 
suffer  from  chronic  urinary  fever,  they  will  not  tolerate  the  slightest 
interference.  The  Bottini  operation  is  too  severe  for  them,  they  die 
after  it,  as  I  have  had  occasion  to  observe  in  my  own  and  other  cases. 
It  is  true  that  they  do  not  live  long  even  when  no  interference  is  prac- 
tised, but  they  last  longer  than  when  they  are  operated  on.  Pyelitis 
or  pyonephrosis,  if  unilateral,  constitutes  no  contraindication  to  the 
operation,  for,  as  is  well  known,  persons  with  these  affections  may  live  a 
long  time.  When  both  kidneys  are  involved,  however,  we  should 
not  operate. 

The  danger  of  haemorrhage,  which  may  occur  either  during  or  after 
operation,  is  not  to  be  underestimated.  It  is  of  great  consequence 
because  it  sometimes  cannot  be  arrested,  styptics  and  the  permanent 
catheter  often  proving  of  no  avail;  even  operative  measures  do  not 
invariably  control  it.  Neither  by  the  suprapubic  nor  perineal  oper- 
ation is  it  always  possible  to  tampon  the  prostate  sufficiently  to 
control  the  bleeding.  I  have  seen  cases  of  prostatic  haemorrhage 
which  could  not  be  stanched.  These  haemorrhages  may  occur  during 
the  operation,  or  afterwards,  when  the  slough  separates.     The  first 

*In  1907  Freudenberg  reported  152  cases  with  a  mortality  of  7  per  cent. 


378  DISEASES    OF    THE    PROSTATE    GLAND. 

are  preventable  if  proper  cases  are  selected  for  operation  and  the 
cauterization  be  thorough  and  protracted.  Proper  cases  are  those 
which  have  shown  no  tendency  to  severe  haemorrhage.  Patients  who 
show  such  a  tendency  I  consider  to  be  very  poor  subjects  for  the  Bottini 
operation. 

As  already  stated,  the  manner  of  cauterization  is  important.  With 
the  knife  at  a  white  heat  four  minutes  should  be  consumed  in  burning 
one  centimeter,  at  which  rate  twelve  minutes  will  be  required  for  an 
incision  three  centimeters  in  length.  The  incisor  should  be  heated 
to  a  white  heat,  because  the  moisture  of  the  tissues  will  reduce  it  to 
a  red  heat;  if  it  be  heated  only  to  a  glow  before  it  is  introduced  it  will 
not  remain  red-hot,  but  will  become  considerably  cooled,  with  the 
result  that  there  is  danger  of  tearing  instead  of  cleanly  dividing  the 
tissues. 

Although  haemorrhage  during  operation  can  be  prevented  by  the 
means  above  mentioned,  there  is  no  way  in  which  bleeding  can  be 
guarded  against  when  the  eschar  separates;  I  have  repeatedly  seen  it 
occur  under  this  circumstance. 

Finally,  sepsis  constitutes  a  great  danger.  The  instrument  can, 
of  course,  be  sterilized,  but  if  the  patient  has  a  purulent  cystitis,  the 
surface  of  the  wound  is  bound  to  be  bathed  with  septic  fluid.  We 
should  not  be  deceived  in  regard  to  this  condition.  In  such  cases  it 
is  imperative  to  previously  cleanse  the  bladder,  and  if  possible  to 
institute  continuous  catheterization  and  employ  irrigations  of  silver 
nitrate.  If  the  cystitis  cannot  be  bettered  by  these  means — which 
seldom  happens — then  it  is  better  not  to  operate. 

The  direct  dangers  of-  the  operation,  namely,  burning  the  wall  of 
the  bladder  or  rectum,  and  injury  to  the  membranous  urethra,  I  con- 
sider of  slight  importance,  as  I  also  do  the  danger  of  dribbling  of  urine 
after  the  operation.  Proper  technic  overcomes  these  dangers.  In 
my  cases  none  of  them  occurred. 

I  managed  my  cases  in  accordance  with  these  principles.  I  cannot 
say  that  the  results  are  brilliant,  but  yet  some  patients  were  cured  and 
many  relieved.  Therefore  I  am  an  advocate  of  the  operation  in 
selected  cases.  On  the  other  hand,  I  do  not  fail  to  recognize  its  dan- 
gers, and,  above  all,  to  realize  that  its  results  are  altogether  uncertain. 

For  these  reasons  I  consider  it  unjustifiable  to  advise  the  operation 
in  the  early  stages  of  the  disease,  at  a  time  when  the  urine  is  clear 
and  only  a  slight  residuum  is  present,  as  in  this  stage  the  patient 


TUBERCULOSIS    OF    THE    PROSTATE.  379 

experiences  little  trouble;  in  the  first  place  we  do  not  know  whether 
the  operation  will  help  him,  and  in  the  second,  we  cannot  tell  but  what 
he  may  continue  to  the  end  of  his  days  in  an  equally  good  condition 
without  operation.  Finally,  even  when  the  operation  proves  of 
benefit  it  does  not  guard  against  recurrence,  as  the  gland  may  con- 
tinue to  grow.  I  have  seen  several  such  cases.  By  a  second  operation, 
however,  it  will  often  be  possible  to  afford  the  patient  relief  again. 

From  the  above  account  it  will  be  seen  that  the  treatment  of  hyper- 
trophy of  the  prostate  is  a  very  satisfactory  undertaking  for  the  sur- 
geon who  is  thoroughly  conversant  with  the  nature  of  the  disease  and 
understands  how  to  individualize.  Those  prostatics  who  cannot  be 
helped  constitute  the  minority;  the  majority  can  be  relieved,  either  by 
or  without  operation,  according  to  their  condition. 

My  views  on  the  various  methods  of  treatment  may  be  summarized 
as  follows: 

i.  For  all  patients  whose  social  condition  permits  them  to  carry  on  a 
careful  and  prolonged  palliative  treatment,  regular  catheterization 
is  at  first  to  be  considered  the  method  of  choice. 

2.  If  catheterization  is  very  difficult  or  very  painful,  if  it  has  to  be 
very  frequently  repeated,  or  if  it  produces  haemorrhage,  then  supra- 
pubic vesical  puncture  or  cystotomy  is  to  be  employed  when  a  major 
operation  is  contraindicated  or  refused. 

3.  When  a  major  operation  is  not  contraindicated  by  advanced 
arteriosclerosis,  cachexia,  or  any  other  serious  organic  disease,  the 
choice  of  procedure  lies  between  the  Bottini  operation  and  suprapubic 
prostatectomy.  According  to  my  experience  the  Bottini  operation, 
as  a  rule,  is  only  palliative.  In  a  few  specially  selected  cases,  however, 
it  affords  permanent  relief. 

4.  Suprapubic  prostatectomy  offers  the  best  chance  for  complete 
cure.  The  relatively  high  mortality  after  this  operation,  however, 
militates  against  its  universal  employment.  It  is  to  be  hoped  that 
improvements  in  technic  will  constantly  reduce  the  mortality  rate. 

5.  Division  of  the  vasa  deferentia  is  to  be  considered  only  in  the 
case  of  those  patients  who  suffer  from  prostatism  or  recurring  epidid- 
ymitis due  to  catheterization. 

TUBERCULOSIS  OF  THE  PROSTATE. 

Tuberculosis  of  the  prostate  usually  affects  young  adults,  rarely 
children  and  old  men.     As  in  most  other  tuberculous  diseases,  hered- 


380  DISEASES    OF   THE    PROSTATE    GLAND. 

itary  predisposition  has  to  be  assumed  in  explanation  of  the  develop- 
ment of  this  malady.  Although  we  are  as  yet  unable  to  explain  the 
exact  nature  of  this  hereditary  influence,  the  fact  remains  that  many 
young  persons  in  whom  there  is  no  apparent  cause  for  the  develop- 
ment of  disease  are  taken  ill  with  an  affection  the  diagnosis  of  which 
is  at  first  obscure,  but  which,  as  it  progresses,  proves  to  be  tuberculosis 
of  the  prostate.  If  the  history  of  such  persons  be  investigated  it  will 
be  found  that  they  belong  to  tuberculous  families.  Weigert  states 
explicitly  that  the  prostate  seems  to  afford  a  particularly  favorable 
soil  for  the  growth  of  infective  microorganisms. 

It  is  easily  conceivable  that  tuberculosis  will  break  out  more  readily 
in  those  having  the  above  mentioned  hereditary  predisposition  when 
they  have  sustained  some  injury  to  the  genital  tract.  A  prominent 
cause,  and  one  the  importance  of  which  was  for  a  long  time  not  suffi- 
ciently recognized,  is  gonorrhoea.  I  have  seen  numberless  cases  of 
urogenital  tuberculosis  involving  the  prostate,  the  soil  for  the  develop- 
ment of  which  had  been  prepared  by  a  long-standing  gonorrhoea. 
Gonorrhoea,  especially  the  chronic  form — which  might  well  be  named 
eternal — is  similar  in  effect  to  an  injury,  which  in  the  predisposed 
favors  the  development  of  tuberculosis  of  the  genital  tract  just  as  it 
does  in  other  organs  of  the  body.  It  has  not  been  proved  that  excesses 
in  venery  or  masturbation  are  causes  of  tuberculosis  of  the  prostate 
in  persons  who  have  no  hereditary  tendency  to  tuberculous  disease, 
and  such  a  theory,  moreover,  is  not  confirmed  by  clinical  experience. 

It  is  conceivable  that  tubercle  bacilli  may  gain  access  to  the  urinary 
passages  from  without,  either  from  cohabitation  with  a  tuberculous 
person  (Cornet)  or  through  infected  catheters,  although  such  occur- 
rences are  rare  in  comparison  with  infection  through  the  blood  or 
lymph-streams. 

This  view  is  corroborated  by  the  circumstance  that  prostatic  tuber- 
culosis seldom  occurs  or  remains  as  a  distinct  and  isolated  disease. 
There  are  almost  always  tuberculous  lesions  in  other  parts  of  the  body. 
It  is  either  preceded  by  phthisis,  or  else  renal  tuberculosis  is  the  pri- 
mary disease;  the  morbid  process  is  either  carried  to  the  prostate 
by  the  blood,  or  reaches  it  by  direct  descent  from  the  kidneys  to  the 
bladder.  In  other  cases  tuberculous  epididymitis  appears  as  the  first 
manifestation  of  disease,  the  prostate  and  seminal  vesicles  becoming 
involved  afterwards.  The  latter  organs  are  very  often  affected  with 
the  prostate.     In  short,  few  cases  have  been  observed  in  which  autopsy 


TUBERCULOSIS    OF    THE    PROSTATE.  381 

showed  the  prostate  alone  to  be  affected.  The  work  of  Jani,  who 
found  tubercle  bacilli  in  the  testes  and  undiseased  prostate  of  the 
subjects  of  phthisis,  is  important  in  showing  the  readiness  with  which 
infective  microorganisms  take  up  their  abode  in  the  latter  organ. 

Pathological  Anatomy.  The  prostate  is  sometimes  enlarged  and 
sometimes  decreased  in  size,  according  to  the  manner  in  which  the 
pathic  process  manifests  itself.  In  this  respect  it  is  well  to  discrim- 
inate between  tuberculosis  of  the  prostate  and  tuberculous  pros- 
tatitis. In  the  first  condition,  which  is  rarely  observed  at  autopsy, 
isolated  nodules  are  found  in  the  acini,  there  being  no  changes,  or  at 
most  only  slight  alterations,  in  the  surrounding  tissue;  whereas  in 
prostatitis  the  alterations  ordinarily  observed  in  this  condition  are 
plainly  discernible.  These  changes  consist  in  an  eruption  of  tubercles, 
at  first  isolated,  later  confluent,  which  pursue  the  same  course  as  they 
always  take  in  other  parts  of  the  body.  In  the  early  stages  there  are 
gray  nodules  in  the  tissue  surrounding  the  acini,  together  with  an 
infiltration  of  round  cells  and  some  giant  and  epithelioid  cells;  later 
the  center  undergoes  caseous  degeneration  and  the  whole  tubercle 
softens,  the  dead  cellular  elements  becoming  converted  into  a  thick, 
greasy,  caseous  mass.  These  small  caseous  collections  are  surrounded 
by  a  zone  of  infiltration.  The  tubercle  bacilli  are  particularly 
abundant  between  the  epithelium  and  its  underlying  connective 
tissue.  The  tubercles  are  more  common  toward  the  periphery 
of  the  gland  than  they  are  near  the  urethra  (the  excentric 
form  of  Thompson  and  Guyon).  The  countless  number  of  these 
small  foci,  which  increase  in  size  and  communicate  with  one  another, 
cause,  in  conjunction  with  the  reactive  inflammation  to  which  they 
give  rise,  considerable  enlargement  of  the  gland.  Its  surface  becomes 
uneven  and  tuberculated;  as  to  consistency,  hard  and  soft  portions 
alternate  with  one  another. 

In  addition  to  caseation,  the  most  common  pathic  process  which 
occurs  in  tubercles,  purulent  disintegration  may  take  place,  as  the 
result  of  which  abscesses  are  formed.  The  number  of  abscesses  de- 
pends upon  the  extent  of  the  destruction  which  takes  place.  In  the 
more  advanced  stages  of  the  disease  these  purulent  collections  coalesce 
and  form  one  large  tuberculous  abscess  which  destroys  more  or  less 
of  the  substance  of  gland. 

Even  when  considerable  alteration  has  been  produced  by  caseation 
and  suppuration  of  many  tubercles  a  relative  cure  may  yet  take  place. 


DISEASES    OF    THE    PROSTATE    GLAND. 

The  contents  of  the  suppurating  and  caseating  cavities  becomes 
resorbed,  or  slowly  undergoes  induration  and  calcification  (Broca). 
Unfortunately,  however,  such  an  occurrence  is  very  rare;  generally 
the  morbid  process  advances  uninterruptedly  toward  the  periphery, 
through  which  it  torces  its  way;  or  the  abscess  may  rupture  externally 
or  break  into  the  urethra  or  bladder.  Thus  the  abscess  may  empty 
itself  completely  at  once,  so  that  a  cavity  with  tuberculous  walls  remains, 
or  if  rupture  takes  place  by  means  of  small  and  irregular  passages,  only 
a  portion  of  the  tuberculous  mass  may  be  evacuated.  The  fistulas 
thus  formed,  which  open  into  the  urethra,  bladder,  perineum,  or  anus 
show  no  tendency  to  heal. 

English  calls  attention  to  an  especially  virulent  form,  tuberculous 
periprostatitis,  which  may  give  rise  to  a  general  dissemination  of 
tuberculosis.  The  tubercle  bacilli  are  carried  to  the  periprostatic 
plexus  by  the  blood  or  lymph-current,  and  they  may  get  out  of  the 
veins  into  the  surrounding  connective  tissue.  Their  presence  in  the 
veins,  too,  may  readily  cause  thrombosis  and  pyaemia. 

Symptoms,  Course  and  Diagnosis.  A  clinical  distinction  also  has 
to  be  made  between  tuberculosis  of  the  prostate  and  tuberculous  pros- 
tatitis. The  first,  that  is,  the  development  of  one  or  more  isolated 
tuberculous  foci  in  the  prostate,  may  take  place  unnoticed,  and  the 
lesion  may  remain  latent  for  years  without  producing  the  slightest 
symptoms.  It  is  only  when  the  process  extends  to  the  adjacent  parts, 
or  the  latter  become  infected  through  the  blood,  or  when  vesical  or 
renal  tuberculosis  breaks  forth  that  symptoms  are  produced,  and  the 
prostate,  upon  examination  through  the  rectum,  is  found  to  be  dis- 
eased with  tubercles  which  must  have  existed  for  a  long  time. 

Thus  it  is  seen  that  a  beginning  tuberculosis  of  the  prostate  confined 
to  the  parenchyma  of  the  gland,  and  not  affecting  the  urethra  and 
bladder,  is  difficult  or  impossible  to  diagnosticate.  As  no  symptoms 
are  present  there  will  be  no  occasion  to  palpate  the  prostate. 

As  concerns  the  subjective  symptoms  which  sooner  or  later  manifest 
themselves,  it  may  be  said  that  they  have  little  which  is  characteristic. 
They  consist  in  disturbances  of  micturition,  pain,  hasmaturia,  and 
hasmospermia. 

.  The  disturbances  of  micturition  have  no  peculiarities.  The  patients 
urinate  more  frequently  by  day  than  by  night,  urination  causing  a 
burning  sensation,  which  is  more  pronounced  at  the  end  of  the  act. 
It  seems  as  though  the  urine  is  expelled  with  difficulty.     This  form  of 


TUBERCULOSIS    OF    THE    PROSTATE.  383 

tenesmus  is  exactly  the  same  as  that  which  is  observed  in  simple 
cystitis  colli,  except  that  it  resists  all  treatment,  whereas  in  the  latter 
disease  good  results  are  obtained. 

Independent  of  micturition  there  is  a  feeling  of  pressure  and  heaviness 
in  the  perineum  and  around  the  anus,  a  painful  sensation  which 
becomes  much  intensified  by  activity,  by  sitting,  and  also  at  stool. 
Here,  again,  the  difficulty  with  which  this  symptom  can  be  overcome 
is  characteristic. 

In  regard  to  haemorrhage,  it  may  be  said  that  severe  bleeding  seldom 
occurs;  on  the  contrary,  usually  only  a  few  drops  of  blood  are  lost, 
this  slight  haemorrhage  sometimes  taking  place  at  the  beginning  of 
micturition,  although  usually  following  the  act.  While  the  same 
phenomenon  is  observed  in  gonorrheal  inflammation  of  the  neck  of 
the  bladder  (cystitis  colli  gonorrhoica),  it  must  not  be  forgotten  that 
one  or  two  instillations  of  silver  nitrate  suffice  to  control  the  bleeding. 
In  tuberculous  prostatitis,  however,  this  treatment  has  an  exactly 
opposite  effect:  it  increases  haemorrhage  and  intensifies  the  pain. 

About  the  same  thing  may  be  said  of  haemospermia.  The  last  drops 
of  semen  expelled  during  coitus,  and  occasionally  also  when  pollutions 
occur,  are  blood-stained;  this  is  a  symptom,  too,  which  is  met  with 
in  simple  inflammation  of  the  seminal  vesicles.  While  in  the  latter 
condition  it  is  characterized  by  benignity,  in  tuberculosis  it  often 
cannot  be  overcome.  On  the  other  hand  it  must  be  remembered 
that  occurrence  of  haemospermia  in  tuberculosis  is  not  constant. 

Although  these  symptoms  of  prostatic  tuberculosis  present  nothing 
specific,  the  diagnosis  can,  however,  be  confirmed  by  physical  exam- 
ination, especially  if  the  constitutional  condition  of  the  patient  be 
thoroughly  investigated  and  his  history  carefully  elicited. 

In  regard  to  urethral  discharge  little  importance  is  to  be  attributed 
to  it,  as  it  is  by  no  means  always  present.  The  disease  must  reach 
the  urethra  and  produce  ulcers  or  fistulous  passages  before  it  can  give 
rise  to  a  discharge  manifesting  itself  at  the  external  orifice,  or  produce 
filaments  in  the  urine.  In  order  to  prove  that  the  discharge  is  tuber- 
culous tubercle  bacilli  must  be  found  in  it,  and  this  is  a  thing  which 
seldom  comes  to  pass ;  moreover,  it  must  be  determined  at  least  beyond 
probable  doubt  that  the  discharge  comes  from  the  prostate.  In  order 
to  determine  this  the  prostate  may  be  massaged,  the  urethra  being 
previously  cleansed,  and  the  secretion  thus  obtained  stained  and 
examined  in  the  usual  manner. 


384  DISEASES    OF    THE    PROSTATE    GLAND. 

A  much  more  certain  method  is  careful  palpation  of  the  prostate 
through  the  rectum.  The  isolated  nodules  can  be  plainly  felt.  They 
occur  in  no  other  prostatic  disease.  The  prostate  is  also  excessively 
sensitive  to  pressure.  If  the  finger  be  long  enough,  the  thickened, 
nodular  and  tortuous  seminal  vesicles  can  be  felt  above  the  prostate. 

Examination  with  the  cystoscope  and  sound  is  unnecessary.  With 
the  cystoscope  nothing  can  be  seen,  for  the  changes  in  the  prostate 
can  at  most  manifest  themselves  at  the  sphincter,  and  similar  changes 
are  also  produced  there  by  ordinary  prostatitis.  The  introduction  of 
a  sound  gives  rise  to  so  much  pain,  and  is  of  such  varied  significance, 
that  it  should  not  be  made  use  of. 

The  above  depicted  subjective  and  objective  symptoms  are  suffi- 
cient to  enable  one  to  make  a  diagnosis,  especially  when  considered 
conjointly  with  the  general  condition  of  the  patient,  knowledge  of 
which  can  be  obtained  by  an  adequate  examination  of  the  entire  body. 
If  the  suspicious  symptoms  are  accompanied  by  a  tuberculous  infection, 
if  the  patient  has  a  hereditary  taint,  if  the  disease  is  characterized  by 
inveterateness  and  resistance  to  treatment,  error  of  diagnosis  will 
seldom  be  made. 

Prognosis.  The  prognosis  is  not  altogether  unfavorable  unless 
there  are  associated  tuberculous  lesions  which  threaten  life.  If,  for 
example,  there  is  in  addition  to  the  prostatic  disease  a  unilateral  renal 
tuberculosis,  cure  is  possible,  and  in  the  case  of  persons  otherwise 
strong,  and  having  good  powers  of  resistance,  it  is  even  probable. 
Cases  in  which  the  disease  ascends,  and  in  which  the  bladder,  epididy- 
mes  and  seminal  vesicles  are  involved  offer  a  much  poorer  prospect 
of  cure.  These  cases  usually  tend  to  bilateral  involvement  of  the 
ureters  and  kidneys,  or  there  are  so  many  associated  tuberculous  foci 
in  the  body  that  cure  is  impossible. 

But  apart  from  remote  localization  of  the  tuberculous  process  the 
disease  progresses  more  commonly  than  it  retrogrades.  Abscesses 
and  fistula?  are  formed  in  the  manner  already  described.  The  thing 
most  to  be  feared  is  the  development  of  the  painful  and  uncontrollable 
vesical  tuberculosis.  Frequently  a  miliary  tuberculosis  brings  an 
end  to  the  patient's  suffering. 

Treatment.  There  is  very  little  to  be  done  for  prostatic  tubercu- 
losis. In  view  of  the  above  described  predisposing  causes,  we  should 
endeavor  by  every  possible  means  to  cure  chronic  gonorrhoea,  so  that 
tuberculosis  may  not  be  superimposed  upon  it.     On  the  other  hand, 


TUBERCULOSIS    OF    THE    PROSTATE.  385 

it  must  not  be  forgotten  that  heroic  treatment  so  weakens  the  organ- 
ism, and  particularly  the  sexual  organs,  that  there  is  danger  of  any 
tubercle  bacilli  which  may  be  in  the  blood  taking  up  their  abode  in 
the  prostate.  For  this  reason  too  active  treatment  is  to  be  avoided. 
Such  diseases  as  urethritis,  epididymitis,  and  prostatitis  occurring  in 
those  predisposed  to  tuberculosis  are  to  be  treated  with  the  utmost 
caution,  and,  if  possible,  without  resort  to  active  local  measures. 

The  medical  treatment  of  tuberculosis  of  the  prostate  with  creasote 
and  similar  drugs  offers  little  hope  of  success.  I  have  never  seen 
any  results  from  their  use. 

Local  applications  of  silver  nitrate,  iodoform,  and  corrosive  subli- 
mate to  the  posterior  urethra  are  to  be  considered  only  when  the 
urethra  is  involved;  under  other  circumstances  their  employment 
is  irrational.  But  even  in  cases  in  which  the  urethra  is  affected  I 
advise  against  their  use.  They  do  little  good  and  cause  the  patient 
much  suffering.  They  do  not  reach  the  source  of  the  tuberculous 
process,  but  merely  a  portion  of  it  which  has  developed  secondarily. 

General  hygienic  measures,  such  as  are  useful  in  other  forms  of 
tuberculosis,  as  for  example,  sanatorium-treatment,  mild  hydrothera- 
peutic  measures,  the  rest-cure,  residence  in  a  southern  climate,  over- 
feeding, and  the  avoidance  of  all  injurious  influences  are  of  value. 
If  micturition  or  defecation  is  very  painful,  the  employment  of  morphine, 
heroin,  or  belladonna  in  the  form  of  rectal  injections  or  suppositories 
is  to  be  recommended.  If  symptoms  referable  to  the  bladder  pre- 
dominate, then  the  sublimate  instillations  used  for  vesical  tuberculosis 
may  be  tried.     Their  effect  is  usually  beneficial. 

Continuous  catheterization  for  the  relief  of  tenesmus  is  not  to  be 
advised,  because  in  tuberculous  cystitis,  which  is  usually  associated, 
the  permanent  catheter  cannot  be  endured.  If  the  pain  and  urgency 
of  urination  become  intolerable,  then  the  only  measure  which  will  bring 
relief  is  puncture  of  the  bladder  and  establishment  of  a  fistula. 

Surgical  treatment  consisting  in  removal  of  the  entire  prostate, 
together  with  the  seminal  vesicles,  as  practised  by  Young  and  others, 
has  as  yet  been  insufficiently  tested  to  enable  us  to  recommend  it. 
Furthermore,  it  would  be  appropriate  only  for  those  cases  in  which 
no  other  tuberculous  foci  exist,  or  for  those  in  which  the  associated 
lesions  are  of  such  a  character  as  to  permit  such  a  formidable  procedure 
and  offer  a  prospect  of  cure. 

It  is  quite  a  different  matter  when  we  have  to  do  with  cold  tuberculous 
26 


386  DISEASES    OF    THE    PROSTATE    GLAND. 

abscesses  of  the  prostate,  or  with  fistulse,  which  are  exceedingly  annoy- 
ing to  the  patient.  Prostatic  abscesses  may  be  opened  through  the 
classical  perineal  incision  or  by  means  of  the  prerectal  incision;  they 
should  then  be  curetted  and  injected  with  iodoform  emulsion.  Fis- 
tulae  should  be  laid  open  and  similarly  treated. 

CONCRETIONS  AND  CALCULI  OF  THE  PROSTATE. 

In  the  prostate  gland  of  every  adult  there  are  small  bodies  called 
stratified  corpuscles,  or  corpula  amylacea,  mention  of  which  has 
already  been  made.  Their  development,  according  to  Virchow,  is  due 
to  thickening  of  the  prostatic  secretion  and  its  cohesion  with  one  or 
more  degenerated  cells  to  form  a  nucleus,  around  which  successive 
layers  are  deposited.  Recklinghausen  considers  them  to  be  closely 
allied  to  starch-corpuscles,  and  Stilling  believes  them  to  be  purely 
amyloid.  Posner's  investigations  show  that  they  are  produced  by 
coagulation  of  albuminous  secretion  or  necrotic  cells,  the  coagulum 
becoming  infiltrated  with  lecithin.  These  become  superimposed 
one  upon  another,  with  the  result  that  concretions  are  formed,  which 
may  attain  the  size  of  a  flax-seed;  they  occur  in  large  numbers  in  the 
acini  and  ducts  of  the  gland.  Their  color  varies  from  light  pearl- 
gray  to  amber,  brown,  or  black.  The  dark  color  is  due  to  pigmentation. 
The  gray  or  brown  granules  are  seen  on  the  cut  surfaces. 

These  stratified  bodies,  aggregations  of  which  form  concretions, 
are  not  a  product  of  disease,  but  are  rather  to  be  considered  as  the 
expression  of  disturbed  glandular  secretion.  They  may  remain  in 
the  prostate  for  years  or  for  a  lifetime  without  causing  any  trouble. 
When  they  increase  sufficiently  in  size,  or  become  incrusted  with 
lime  salts  to  such  an  extent  that  they  project  above  the  level  of  the 
urethra,  it  is  then  that  they  are  often  first  recognized.  As  a  rule,  they 
remain  small;  when  deposits  of  carbonate  or  oxalate  of  lime,  or  triple 
phosphates,  are  added  to  them  they  become  true  calculi. 

Entirely  different  in  origin  from  these  are  those  stones  which  lie 
in  the  prostatic  urethra;  they  are  either  true  urethral  calculi  or  frag- 
ments of  vesical  calculi.  To  the  latter  category  belong  the  so-called 
pipe-stones,  which  lie  partly  in  the  bladder  and  partly  in  the  urethra, 
being  bent  at  an  angle  after  the  manner  of  a  pipe-head. 

Those  which  have  received  the  name  of  hour-glass  calculi  because 
the  expanded  ends  are  united  by  a  slender  median  portion  may  be 
urethral,  vesical,  or  prostatic.     These  stones  result  from  the  deposition 


CONCRETIONS    AND    CALCULI    OF    THE    PROSTATE.  387 

of  urinary  salts  upon  the  primary  calculus.  True  prostatic  calculi 
are  seldom  singular,  generally  being  present  in  large  numbers.  Gold- 
ing-Bird  describes  a  case  in  which  there  were  one  hundred  and  thirty 
calculi  in  the  prostate.  Calculi  in  the  prostatic  urethra,  on  the  con- 
trary, are  usually  single.  The  larger  their  number  the  smaller  they 
are,  and  vice  versa.  Stones  weighing  as  much  as  120  grammes  [1800 
grains]  have  been  found. 

If  the  prostate  undergoes  calcareous  degeneration  in  the  manner 
thus  described,  the  calculi  generally  lie  in  cavities  which  are  irregularly 
distributed  throughout  the  entire  gland,  although  they  may  be  confined 
to  certain  portions,  or  perhaps  to  one  side,  of  the  gland.  If  there  is  a 
single  stone  of  considerable  size,  the  substance  of  the  gland  around  it 
atrophies,  and  the  cavity  in  which  it  is  then  contained  will  be  surrounded 
by  a  zone  of  atrophied  tissue. 

Incrustations  must  also  be  included  with  prostatic  calculi,  although 
in  origin  they  differ  from  the  latter,  originating  as  they  do  from  small 
circumscribed  collections  of  pus  which  undergo  inspissation  and 
calcification,     They  are  extremely  rare. 

The  same  is  true  of  venous  calculi,  or  phleboliths,  which  occur  in 
the  dilated  veins  of  the  periprostatic  plexus.  They  seldom  attain  a 
size  larger  than  a  pea.  Their  development  is  favored  by  dilatation 
of  the  veins  and  also  by  venous  stasis.  Phleboliths  also  are  very 
rare. 

In  general  it  may  be  said  that  prostatic  concretions  and  calculi  pro- 
duce no  symptoms,  and  therefore  that  their  existence  cannot  be  deter- 
mined. They  are  only  discovered  during  operation  or  found  post- 
mortem. Sometimes,  however,  especially  if  they  protrude  into  the 
urethra,  they  give  rise  to  trouble,  producing  difficult  and  painful 
micturition.  The  patient  has  to  urinate  oftener  than  usual  and  there 
is  perceptible  resistance  to  the  outflow  of  urine;  it  is  noteworthy  that 
this  resistance  is  not  constant,  being  present  at  times  and  absent  at 
others.  The  condition  is  analogous  to  that  which  obtains  when 
small  vesical  calculi  are  carried  to  the  neck  of  the  bladder  and  occlude 
it.  Complete  retention  of  urine  may  result.  Urination  is  painful, 
the  pain  radiating  to  the  tip  of  the  penis.  Defecation  likewise  causes 
pain.  The  patient  also  experiences  a  sense  of  heaviness  and  pressure 
in  the  perineum  existing  independently  of  micturition. 

Haemorrhages  due  to  prostatic  calculi  are  not  frequent,  although 
they  sometimes  occur.     When    the    stone  projects  into  the  urethra 


388  DISEASES    OF    THE    PROSTATE    GLAND. 

blood- cells  are  almost  always  found  in  the  urine.  In  one  case  I  saw 
a  severe  and  almost  fatal  haemorrhage  produced  by  a  calculus  a  little 
larger  than  a  pea,  the  sharp  edge  of  which  jutted  out  into  the  urethra. 
The  patient  died  a  few  weeks  later  and  the  above  described  condition 
was  revealed  at  autopsy. 

Other  inflammatory  processes  also  not  uncommonly  make  their 
appearance  in  the  posterior  urethra  and  bladder  without  causing 
the  urine  to  show  the  characteristics  of  cystitis.  The  calculi  have 
eroded  the  urethral  mucosa  and  produced  small  areas  of  necrosis. 
If  the  stone  is  expelled,  the  urethral  inflammation  usually  subsides, 
although  it  sometimes  resists  all  treatment. 

The  expulsion  of  the  calculi  occurs  in  one  of  two  ways:  either  they 
escape  from  the  prostatic  ducts  into  the  urethra,  or  they  ulcerate 
their  way  through  the  substance  of  the  prostate  and  thus  reach  the 
canal,  from  which  they  are  then  washed  away  by  the  urine.  They 
may  also  be  carried  backward  into  the  bladder,  and  become  vesical 
calculi. 

If  they  lie  further  away  from  the  periphery,  more  toward  the  center 
of  the  gland,  they  lead  to  inflammatory  phenomena,  as  the  result 
of  which  atrophy  takes  place. 

Such  an  occurrence  renders  diagnosis  more  easy  for  the  reason 
that  the  stone  can  then  be  detected  by  palpation  through  the  rectum. 
It  is  this  circumstance  which  first  leads  to  certainty  of  diagnosis,  for 
the  above  described  subjective  symptoms  of  difficult,  painful  and 
interrupted  micturition  are  too  ambiguous  to  permit  the  nature  of  the 
trouble  to  be  determined.  With  the  finger  in  the  rectum  the  uneven, 
hard  and  enlarged  prostate  can  be  palpated,  and  at  times  the  grating 
of  one  calculus  upon  another  can  be  felt. 

If  a  metal  sound  be  introduced  into  the  urethra,  those  stones,  and 
only  those,  of  course,  which  project  into  its  lumen  can  be  felt.  The 
sensation  imparted  cannot  be  mistaken ;  it  consists  in  a  distinct  grating 
or  crepitation.  Naturally  this  is  not  characteristic  of  prostatic  calculi 
alone,  for  urethral  calculi  give  the  same  results.  If  simultaneous  palpa- 
tion with  a  sound  in  the  urethra  and  a  finger  in  the  rectum  be  practised, 
it  may  happen  that  a  hard  body  will  be  detected  between  the  two. 

Radioscopy  is  to  be  considered  as  a  further  means  of  diagnosis; 
the  bladder  and  rectum  must  be  empty  when  the  examination  is  made. 
Golding-Bird  has  succeeded  in  obtaining  very  good  X-ray  pictures 
of  prostatic  calculi.     Proof  is  obtained  only  when  the  picture  is  positive. 


NEW    GROWTHS    OF    THE    PROSTATE.  389 

Prostatic  calculi  may  be  present  even  though  no  shadow  appears  on 
the  plate,  for  the  X-rays  are  not  absorbed  by  all  varieties.  Owing  to 
the  rarity  of  prostatic  calculi  it  is  evident  that  this  method  is  yet  in 
its  formative  stage. 

Treatment.  In  those  cases  in  which  the  calculi,  which  perhaps 
have  been  discovered  accidentally,  produce  no  trouble,  treatment  is 
unnecessary.  Even  when  pain  and  difficulty  of  micturition  are  occa- 
sionally experienced  the  surgeon  may  wait  to  see  whether  the  stone 
will  not  be  spontaneously  expelled  before  resorting  to  treatment, 
which,  because  of  the  nature  of  the  condition,  can  only  be  surgical. 

If  the  trouble  increases,  if  inflammation  and  suppuration  ensue, 
and  if  there  are  grounds  for  believing  that  the  calculus  or  calculi 
are  becoming  larger,  then,  of  course,  operation  is  necessary.  Crushing 
and  evacuation  through  the  natural  passages,  the  lateral  prostatic 
incision,  similar  to  that  made  in  lateral  lithotomy  (Dupuytren),  and 
opening  the  prostate  through  the  rectum  (Mazzoni),  have  been  aban- 
doned. The  only  choice  to  be  made  is  between  the  perineal  and  the 
prerectal  incision  (Demarquay,  Dittel,  Zuckerkandl,  Socin).  The 
latter  is  constantly  winning  more  supporters,  because  the  prostate 
can  be  reached  more  surely  and  safely  by  it.  If  the  calculi  are  firmly 
imbedded  in  the  substance  of  the  gland,  it  may  be  necessary  to  use  a 
stone-spoon,  or  some  instrument  which  affords  leverage,  to  get  them 
out.  The  prognosis  of  the  operation,  as  of  the  disease  itself,  is  favorable, 
and  cure  usually  takes  place  without  any  difficulty. 

NEW  GROWTHS  OF  THE  PROSTATE. 

The  only  new  growths  of  the  prostate  which  we  shall  consider  here 
are  the  malignant  ones,  carcinoma  and  sarcoma;  the  benign  growths, 
fibromyoma  and  adenoma,  were  designated  as  hypertrophy  of  the 
prostate  and  described  as  such.  The  malignant  tumors  are  almost 
always  primary;  it  is  very  rare  for  them  to  be  secondary.  The  latter 
form  may  be  due  to  direct  extension  from  a  neighboring  growth, 
as  for  example,  intestinal  carcinoma;  or  it  may  be  caused  by  metas- 
tasis from  a  growth  more  remotely  situated,  such  as  cancer  of  the 
stomach,  dura  mater,  or  penis.  It  is  worthy  of  notice  that  malignant 
vesical  tumors  have  no  tendency  to  invade  the  prostate,  although 
prostatic  growths  often  extend  to  the  bladder. 

That  an  ordinary  prostatic  hypertrophy  may  be  transformed  into  a 


390  DISEASES    OF    THE    PROSTATE    GLAND. 

carcinoma,  as  Albarran  and  Halle  have  stated,  does  not  seem  to  me 
to  have  been  proved.  The  theory  that  the  seeming  hypertrophy 
was  a  slowly  progressive  malignant  neoplasm  is  irrefutable. 

The  causes  are  entirely  unknown,  as  is  the  case  with  malignant 
disease  of  other  organs.  That  heredity  or  gonorrhoea  plays  a  role 
has  not  been  proved,  and  it  is  particularly  improbable  that  the  latter 
has  any  causative  influence  in  their  evolution.  Carcinoma  shows  a 
predilection  for  old  people.  In  children  and  young  men  it  is  very 
Tare.  Sarcoma,  on  the  contrary,  has  often  been  observed  in  early 
childhood.  Klebs  attributes  the  latter  circumstance  to  intrauterine 
influences. 

PATHOLOGICAL  ANATOMY. 

Carcinoma  of  the  prostate  occurs  in  two  principle  forms,  the  soft, 
medullary,  or  adeno- carcinoma,  also  called  epithelioma,  and  the 
hard  or  schirrus  form.  Macroscopically  the  diffuse  and  circum- 
scribed forms  require  differentiation. 

Medullary  or  adeno-carcinoma  is  characterized  by  its  softness 
and  succulency.  The  small  mononuclear  cells  are  imbedded  in  a 
delicate  fibrillary  stroma.  Orth  describes  them  as  follows:  "Micro- 
scopically the  cancer  is  a  cylindric  cell  new  growth,  the  cells  often  being 
arranged  in  gland-like  ducts  or  tubes,  so  that  adeno-carcinoma  must 
be  diagnosticated.  The  stroma  may  either  be  normal  or  show  small- 
celled  infiltration,  being  in  the  latter  case  involved  in  the  neoplasm." 

It  is  upon  this  condition  that  Albarran  and  Halle  base  their  theory 
of  the  transformation  of  simple  prostatic  hypertrophy  into  carcinoma. 

As  already  stated,  the  growth  may  be  diffuse  or  circumscribed. 
In  the  latter  case  only  one,  or  at  most  a  few  portions,  of  the  gland  are 
affected  and  show  the  characteristic  signs  of  the  disease,  the  remaining 
part  showing  typical  prostatic  tissue.  These  more  rare  forms  are  of 
slow  growth.     The  prostate  usually  does  not  attain  a  large  size. 

In  sharp  contradistinction  to  these  tumors  are  those  which  affect 
more  or  less  of  the  entire  gland,  and  advance  rapidly  to  the  surrounding 
tissue.  They  soon  break  through  the  capsule  of  the  prostate  and 
extend  to  the  small  pelvis,  filling  it  with  tumor-masses,  and  go  on  to 
the  seminal  vesicles,  the  ureters,  the  perineum,  and  the  innominate 
bones. 

Guyon  has  named  these  forms,  which  are  characterized  by  enor- 
mous size,  diffuse  prostato-pelvic  carcinoma.     This  large  tumor  may 


NEW    GROWTHS    OF    THE    PROSTATE. 


391 


either  be  of  homogeneous  consistency,  or  present  alternating  hard  and 
soft  portions.  The  surface  is  lobulated,  uneven,  and  hard,  and  the 
mucous  membrane  of  the  rectum  is  adherent  to  it.  These  tumors  grow 
through  the  bladder,  proliferating  freely,  so  that  when  viewed  through 
the  cystoscope  they  simulate  typical  vesical  neoplasms ;  or  they  may  push 
the  vesical  mucosa  in  front  of  them,  so  that  the  convexity  shown  in 
the  cystoscopic  picture  appears  to  be  covered  with  hyperaemic,  though 
otherwise  normal,  membrane. 

The  rectal  mucosa  is  simultaneously  affected;  the  carcinomatous 
masses  ulcerate  and  give  rise  to  a  malodorous  discharge.  Later, 
or  perhaps  at  the  same  time,  the  lymph-glands  situated  near  the 


Fig. 


-Extension  of  carcinoma  through  the 
lymph-glands.      (Musee  Guyon.) 


prostate  become  infiltrated;  the  mesenteric,  inguinal  and  retroper- 
itoneal glands  are  affected  (Fig.  198).  Secondary  nodules  are  found 
in  the  liver,  the  pleura,  the  lungs,  the  corpora  cavernosa,  the  kidneys 
and  spleen. 

Different  from  these  in  form,  structure,  and  evolution,  as  well  as  in 
the  manner  in  which  they  produce  metastases,  are  the  osteoplastic 
carcinomata  of  the  prostate,  which  have  been  studied  by  Reck- 
linghausen. 

The  remarkable  thing  about  them  is  that  the  primary  lesion  in  the 
prostate  is  small  and  insignificant  in  comparison  with  the  abundant 
and  widely  disseminated  bone-metastases. 


392  DISEASES    OF    THE    PROSTATE    GLAND. 

While  the  primary  focus  is  often  so  small  that  it  is  not  demonstrable 
clinically,  and  is  even  hard  to  find  at  autopsy,  numerous  diffuse  carci- 
nomatous infiltrations  of  bone  are  always  present.  They  affect  the 
pelvis,  the  lower  portion  of  the  vertebral  column,  the  joints  of  the 
lower  extremity,  the  ribs,  the  sternum,  the  scapula,  the  humerus, 
and  the  bones  01  the  skull,  showing  a  special  predilection  for  the 
lower  end  of  the  femur  and  humerus.  The  internal  organs  are 
usually  not  involved. 

Von  Recklinghausen  describes  the  changes  in  the  bones  as  follows: 
"there  is  wide  spread  sclerosis  and  eburnation  of  parts  which  are 
normally  spongy,  or  in  which  cavities  are  present,  such  as  the  epi- 
physes and  diaphyses  of  the  long  bones,  the  vertebra?,  etc.;  extensive 
resorption  and  atrophy  of  compact  bone  tissue  alternate  irregularly 
with  one  another.  In  addition  to  these  changes  marked  thickening 
of  the  diseased  parts  is  produced  by  deposition  of  new  bone  tissue 
in  the  form  of  spicules  resembling  stalactites,  the  spaces  between 
them  and  the  canaliculi  being  filled  with  cancer  cells."  The  cancer 
proliferates  more  rapidly  than  it  disintegrates,  so  that  its  nature  is 
not  markedly  destructive  (Von  Frisch).  The  metastases  are  of  mye- 
logenous origin.  "The  seed  of  these  growths  is  disseminated  in  the 
bone-marrow,  and  the  growth  takes  place  outward  and  perforates 
the  bone." 

Osseous  cancer  extends  along  the  course  of  the  blood-vessels,  and 
breaks  through  the  vessels  at  the  surface  of  the  bone.  These  osseous 
metastases  show  the  same  structure  as  the  primary  prostatic  focus 
of  disease,  consisting  of  connective  tissue  alveoli  filled  with  cuboid 
and  cylindric  cells.  Just  as  cancer  of  the  mammary  gland  is  the 
most  common  cause  of  carcinomatosis  in  woman,  so  likewise  is  prostatic 
carcinoma  often  responsible  for  general  diffusion  of  cancer  in  man, 

It  has  already  been  stated  that  sarcoma  is  considerably  rarer 
than  carcinoma,  and  that  it  occurs  particularly  in  the  earliest  years  of 
childhood  and  in  old  age.  This  disease  is  almost  exclusively  primary. 
A  few  exceptional  cases  of  secondary  sarcoma  which  has  extended 
from  other  structures,  such  as  the  seminal  vesicles  or  bones,  for  instance, 
have  been  reported. 

The  tumor  is  almost  always  composed  of  round  or  spindle-shaped 
cells,  and  in  the  beginning  of  its  development  its  limits  are  sharply 
defined;  it  looks  like  a  fibroma  embedded  in  the  substance  of  the 
gland. 


NEW    GROWTHS    OF    THE    PROSTATE.  393 

As  proliferation  advances  first  a  portion  and  finally  the  entire  gland 
becomes  transformed  into  a  malignant  growth.  Proliferation  does 
not  stop  here.  Sarcomata  are  characterized  by  their  large  size  and 
rapid  growth.  It  is  less  common  for  sarcoma  of  the  prostate  to  be 
diagnosticated  when  it  has  merely  grown  sufficiently  to  cause  the 
middle  lobe  to  protrude  into  the  bladder  as  a  pedunculated  fungous 
mass,  than  it  is  for  it  to  be  found  extending  in  various  directions  and 
involving  many  different  structures.  It  fills  the  true  pelvis,  com- 
presses the  ureters,  grows  around  the  bladder,  pushes  outwards  and 
forwards ;  occasionally,  too,  it  grows  through  the  bladder  and  narrows 
the  broad  expansion  of  the  rectum. 

The  metastases,  in  contradistinction  to  those  of  carcinoma,  are 
characterized  by  the  fact  that  they  appear  late  in  the  disease  and  that 
they  affect  in  comparatively  small  measure  the  inguinal  and  other 
neighboring  glands,  which  are  extensively  involved  in  carcinoma. 
Generally  there  are  metastases  of  remote  organs,  such  as  the  liver, 
pancreas  and  lungs,  before  the  lymph-glands  of  the  pelvis  become 
affected. 

SYMPTOMS,    COURSE    AND   DIAGNOSIS. 

We  will  first  consider  prostatic  sarcoma  as  it  occurs  in  childhood, 
and  which  is  first  discovered  when  retention  of  urine  develops  suddenly 
and  without  apparent  cause.  If  these  little  patients  be  examined 
a  tumor  of  considerable  size  will  be  found.  In  some  cases  difficult 
and  painful  micturition,  pain  upon  defecation,  and  sometimes,  though 
rarely,  the  occurrence  of  urinary  haemorrhage,  will  first  attract  notice 
and  bring  the  case  to  the  surgeon's  attention.  When  palpation  is 
practised,  especially  bimanual,  a  tumor  will  be  felt  through  the  rectum 
where  the  prostate  would  lie  later  in  life.  This  growth  is  hard,  and 
often  presents  projections  which  reach  to  the  symphysis  and  bladder. 
The  tumor  develops  rapidly  and  death  invariably  ensues  in  from  one 
to  two  years  after  the  beginning  of  the  disease. 

The  symptoms  of  carcinoma  and  sarcoma  in  adults  are  so  near 
alike  that  they  may  be  considered  conjointly.  A  few  minor  differences 
will  be  pointed  out.  The  symptoms  consist  in  disturbances  of  mic- 
turition— of  pain  occurring  both  in  association  and  independently 
thereof — and  in  disturbances  of  defecation;  objectively  the  general 
cachexia,  the  presence  of  blood  and  pus  in  the  urine,  and  perhaps 


394  DISEASES    OF    THE    PROSTATE    GLAND. 

of  fragments  of  tissue,  the  results  obtained  by  sounding,  cystoscopy, 
and  rectal  palpation,  together  with  the  demonstration  of  metastases, 
confirm  the  diagnosis. 

The  disturbances  of  micturition  are  essentially  the  same  as  those 
of  prostatic  hypertrophy.  According  to  the  size  of  the  growth,  and  the 
interference  with  the  normal  relation  of  the  part  which  it  produces, 
the  patient  is  compelled  to  strain  more  or  less  in  order  to  void  his 
urine;  the  stream  loses  its  former  projectile  power.  The  frequency 
of  micturition  is  increased  in  varying  degree,  the  bladder  gradually 
comes  to  empty  itself  with  more  and  more  difficulty,  and  chronic 
incomplete  retention,  which  may  become  converted  into  complete 
retention,  soon  ensues.  The  latter,  however,  is  less  frequent  than 
in  hypertrophy  of  the  prostate.  In  such  cases  involuntary  voiding 
of  urine  may,  of  course,  take  place ;  in  other  words  overflow  of  the  blad- 
der occurs.  Incontinence  of  urine,  which  also  occasionally  occurs,  is 
different  from  this,  coming  on,  as  a  rule,  toward  the  end  of  the  disease, 
and  being  due  to  interference  with  the  sphincter  by  the  new  growth. 

Pain  upon  urination  is  a  typical  symptom;  it  is  characterized  by  the 
fact  that  it  can  be  relieved  only  slightly  and  for  short  periods  at  a 
time.     If  the  use  of  narcotics  be  discontinued  it  returns  at  once. 

A  more  characteristic  point  of  difference  between  the  pain  of  malig- 
nant disease  and  that  of  prostatic  hypertrophy,  is  that  the  former  is 
not  only  present  during  micturition,  but  that  it  remains  constantly 
with  the  patient.  It  is  located  in  the  glans  and  root  of  the  penis,  in 
the  rectum,  in  the  perineum,  in  the  hypogastrium,  and  also  in  the 
sacral  region.  Severe  exacerbations  may  occur.  As  the  pain  is 
unremitting,  it  may  seriously  impair  the  patient's  strength. 

It  extends  along  the  ischiatic  and  crural  nerves;  the  whole  region 
supplied  by  the  sacral  and  lumbar  plexus  may  be  affected.  There  is 
no  doubt  that  these  pains  are  evoked  through  compression  of  nerve- 
trunks  by  the  tumor  and  its  metastatic  glandular  swellings.  This 
view  is  corroborated  by  the  persistence  and  obstinacy  of  the  pain, 
which  cannot  be  overcome;  the  circumstance  that  the  prostate  is  as 
yet  relatively  small  at  the  time  these  pains  occur  does  not  militate 
against  it,  for  we  know  that  small  tumors  of  the  lymphatic  glands  may 
be  accompanied  by  metastatic  processes  of  considerable  size. 

As  regards  the  last  class  of  subjective  symptoms,  namely,  the  dis- 
turbances referable  to  the  rectum,  it  may  be  stated  that  they  are  the 
same  as  those  occurring  in  simple  hypertrophy.     Evacuation  of  the 


NEW    GROWTHS    OF    THE    PROSTATE.  395 

bowels  is  difficult,  and  chronic  constipation,  which  may  become  so 
severe  as  to  constitute  complete  obstruction,  results. 

A  circumstance  worthy  of  attention,  too,  is  that  defecation  is  often 
attended  by  pain,  a  symptom  winch  is  absent  in  prostatic  hypertrophy. 
If  the  tumor  attacks  the  rectal  mucosa  itself  and  causes  ulceration, 
a  severe  catarrh  is  produced,  the  secretion  being  thick  and  bloody  and 
containing  particles  of  decayed  tissue. 

Of  the  objective  symptoms,  cachexia  will  at  once  attract  notice. 
The  face  is  sallow  and  the  body  emaciated;  the  patient  cannot  be 
made  to  gain  weight  even  under  the  most  careful  nourishment.  It 
is  true  that  prostatics  occasionally  show  the  same  picture  of  bodily 
decline,  especially  when  they  are  suffering  from  urinary  infection, 
but  it  is  possible  to  distinguish  between  the  two. 

The  cachexia  of  prostatics,  evoked  by  exacerbations  and  compli- 
cations, proves  to  be  transitory.  If  the  complications  are  subdued, 
the  patient  usually  improves  and  his  general  condition  becomes  better; 
the  symptoms  of  urinary  infection  subside.  The  absorption  of 
intensely  purulent  and  decomposing  urine  is  recognized  as  the  cause 
of  the  decline  in  these  cases.  In  the  cachexia  of  malignant  disease, 
on  the  contrary,  the  urine  may  be  perfectly  clear,  or  show  only  the 
most  trivial  departures  from  the  normal.  Loss  of  weight  and  progres- 
sive weakness  are  incessant. 

As  just  stated  marked  changes  in  the  urine  are,  as  a  rule,  not  present. 
There  is  usually  some  pus  and  occasionally  some  blood,  and  when  the 
tumor  pushes  its  way  into  the  bladder  fragments  of  tumor  may  be 
voided.  The  last  phenomenon  is  so  rare,  however,  that  it  cannot 
be  reckoned  upon  as  a  help  in  making  a  diagnosis.  Admixture  of  pus 
with  the  urine  is  much  more  common.  The  circulatory  disturbances 
which  are  produced  in  the  bladder  by  the  tumor  naturally  prepare  a 
favorable  field  for  the  reception  of  infective  microorganisms.  It  is 
rare,  though,  for  the  cystitis  to  assume  any  great  degree  of  severity. 

Urinary  haemorrhage  due  to  prostatic  tumors  has  nothing  character- 
istic about  it.  The  bleeding  may  be  either  initial  or  terminal,  or  the 
blood  may  come  out  of  the  bladder  thoroughly  mixed  with  the  urine. 
Haemorrhage  occurs  not  only  when  the  tumor  has  broken  into  the 
bladder,  but  may  also  take  place  as  the  result  of  venous  stasis  produced 
by  the  prostatic  tumor  growing  around  the  bladder.  In  common  with 
all  haemorrhages  due  to  tumors  of  the  bladder  the  bleeding  occurs 
without  apparent  cause,  resists  all  treatment,  and  disappears  spon- 


396  DISEASES    OF    THE    PROSTATE    GLAND. 

taneously;  it  is  neither  excited  by  activity  nor  can  it  be  subdued  by 
rest. 

It  differs  from  ordinary  vesical  haemorrhage  in  being  less  profuse; 
very  copious  bleeding  from  prostatic  tumors  is  exceptional. 

In  regard  to  examination  with  sounds  and  the  cystoscope  we  should 
be  forewarned  that  it  usually  proves  deleterious.  The  sound  generally 
shows  that  the  urethra  is  displaced,  the  same  as  in  hypertrophy  of 
the  prostate.  There  are  deviations  which  fender  the  passage  of  an 
inflexible  instrument  into  the  bladder  very  difficult.  I  have  seen 
cases  in  which  it  was  absolutely  impossible  to  get  a  metal  sound  into 
the  bladder,  whereas  a  flexible  bougie  went  in  with  ease.  For  this 
reason  soft  instruments  are  to  be  preferred  for  examination  as  well  as 
for  treatment.  Slight  haemorrhage  generally  follows  the  use  of  instru- 
ments. 

Examination  with  the  short-beaked  cystoscope  may  also  be  very 
difficult  and  impracticable.  If  the  cystoscope  can  be  introduced 
into  the  bladder  without  producing  haemorrhage,  or  if  the  bladder  can 
be  freed  from  blood  which  has  escaped  as  the  result  of  instrumenta- 
tion, it  will  be  seen  that  the  tumor  of  the  prostate  has  either  pushed 
its  way  into  the  bladder,  carrying  the  vesical  mucous  membrane  before 
it,  or  that  it  has  broken  through  the  vesical  wall.  When  the  tumor  is 
covered  by  mucous  membrane  the  latter  appears  entirely  normal  except 
that  it  is  somewhat  injected;  when  the  tumor  has  ruptured  the  bladder- 
wall  the  cystoscopic  picture  is  not  different  from  the  one  generally 
presented  by  vesical  tumors.  In  such  cases  rectal  palpation  will 
clear  up  all  doubt,  as  in  vesical  tumors  the  prostate  is  normal. 

Oftentimes  the  results  of  rectal  palpation  are  so  precise  that  from 
them  alone  the  diagnosis  of  prostatic  tumor  can  be  made.  One  must 
take  the  precaution  to  examine  when  the  bladder  is  empty,  for  if  the 
examination  be  made  when  it  is  full,  errors  are  likely  to  result.  When- 
ever possible  bimanual  palpation  should  be  employed.  The  prostate 
is  almost  always  considerably  enlarged.  The  initial  elements  of  disease 
which  have  not  yet  led  to  enlargement  can  of  course  not  be  felt,  but 
such  a  condition  of  affairs  is  very  unusual. 

The  surface  of  the  prostate  usually  presents  marked  irregularities, 
and  is  exceptionally  firm  and  dense;  occasionally  it  is  as  hard  as  wood, 
a  condition  which  does  not  obtain  in  simple  hypertrophy.  The  rectal 
mucous  membrane  covering  the  tumor  is  not  movable.  If,  in  addition, 
there  is  irregularity  in  the  extension  of  the  tumor,  for  instance  if  hard 


NEW    GROWTHS    OF    THE    PROSTATE.  397 

conical  projections  grow  out  into  the  surrounding  tissue  upwards  or 
laterally,  so  that  the  gland  cannot  be  outlined,  there  will  be  no  doubt 
that  we  are  dealing  with  a  tumor,  and  not  with  hypertrophy  of  the 
prostate.  These  hom-like  offshoots  extending  in  different  directions — 
now  toward  the  seminal  vesicles,  now  laterally  to  the  wall  of  the  pelvis — 
are  typical  of  tumors  both  as  to  form  and  hardness.  In  order  to  feel 
anything  by  bimanual  palpation  the  patient  must  be  thin  and  the 
abdominal  walls  compressible. 

Finally,  if  metastases  can  be  felt,  for  example, in  the  inguinal  region; 
or  if  there  is  probability  of  their  existence  in  the  viscera;  or  if  incessant 
pain  in  the  legs,  in  the  region  of  the  sacrum,  or  in  the  shoulders  make 
it  seem  likely  that  metastases  are  pressing  upon  nerve-trunks  and 
invading  the  bones ;  and  if  the  lower  extremities  show  signs  of  oedema, 
which  point  to  the  presence  of  venous  thrombi,  the  diagnosis  becomes 
less  and  less  doubtful. 

The  course  of  the  disease  usually  proves  to  be  most  painful.  In 
some  cases  vesical  symptoms  predominate,  in  others  rectal,  and  in  still 
others  neuralgic.  The  duration  of  the  disease  does  not  exceed  five 
years.  The  malady  begins  with  symptoms  similar  to  those  of  prostatic 
hypertrophy,  but  haemorrhage  soon  manifests  itself,  and  it  is  not  long 
before  painful  micturition,  together  with  pain  in  the  bones  and  sharp, 
shooting  pains  along  the  course  of  the  nerves  are  superadded  to  the 
other  symptoms.  Cachexia  comes  more  and  more  to  the  front,  but,  as  a 
rule,  before  the  patient  succumbs  to  it,  complications  ensue  which  cause 
a  more  speedy  termination  of  the  disease  than  would  result  from  this 
gradually  progressive  decline.  Retention  of  urine,  intestinal  obstruc- 
tion, compression  of  the  ureters  with  consequent  hydro-  and  pyo- 
nephrosis, anuria,  infection  of  the  bladder,  erosion  of  the  vertebrae 
resulting  in  total  haemiplegia  (which  I  have  twice  seen),  thrombosis 
of  the  pelvic  veins,  and  finally  hypostatic  pneumonia,  constitute  the 
direct  and  indirect  causes  of  death. 

TREATMENT. 

The  treatment  of  malignant  tumors  of  the  prostate  is  entirely 
symptomatic.  We  must  be  satisfied  with  lessening  the  patient's 
pain  and  trying  to  sustain  his  strength.  For  the  control  of  pain 
narcotics  in  the  most  varied  forms  cannot  be  dispensed  with.  Morphine, 
belladonna,  heroin,  and  dionin  by  mouth,  and  by  rectum  in  the  form 


398  DISEASES    OF    THE    PROSTATE    GLAND. 

of  injections,  are  useful;  when  given  per  rectum  pyramidon  or  anti- 
pyrin  may  be  combined  with  them.  Hot  sitz-baths,  hot  applications, 
the  thermophore — in  fact  heat  in  all  its  forms — are  useful.  Catheter- 
ization should  be  employed  both  for  complete  and  incomplete  re- 
tention of  urine. 

I  will  again  call  attention  to  the  fact  that  only  soft  instruments 
are  to  be  used.  The  condition  of  the  bowels  must  be  looked  after; 
evacuations  are  best  secured  by  means  of  high  enemata.  A  generous 
diet  should  be  provided.  Local  treatment  is  not  to  be  made  use  of 
except  when  it  is  specially  indicated,  for  instance,  when  retention  of 
urine  takes  place,  or  when  suppuration  cannot  be  controlled  by  other 
measures.  Formidable  methods  of  examination,  such  as  cystoscopy, 
should  not  be  resorted  to  unless  absolutely  necessary  for  making  a 
diagnosis. 

Radical  treatment  of  prostatic  tumors,  having  in  view  the  removal 
of  the  entire  neoplasm,  is  to  be  advised  against,  because,  judging 
from  the  results  thus  far  obtained,  it  shortens  life.  Partial  removal 
of  the  gland  is  irrational,  because  it  is  impossible  to  say  whether 
diseased  areas  are  not  contained  in  the  portion  which  remains  behind. 
Nothing  short  of  complete  extirpation  is  to  be  considered,  and  even 
this  can  offer  hope  of  results  only  when  it  is  undertaken  before  metas- 
tases have  occurred.  The  prospects  of  success  are  exceedingly  small, 
because  the  tumor  has  usually  existed  a  long  time  before  its  real  nature 
is  learned. 

These  considerations  are  in  accord  with  the  following  results  obtained 
by  operation.  Billroth's  patient,  the  first  ever  operated  on,  recovered 
from  the  operation,  but  died  fourteen  months  later  of  a  recurrence; 
Stein's  first  patient  died  at  the  end  of  nine  months;  his  second  patient, 
and  also  Leisrink's  and  Depages's  did  not  survive  the  operation.  In 
Verhoogen's  case  death  due  to  recurrence  of  the  disease  took  place  in 
nine  months,  and  in  Fuller's  in  eleven  months.  Socin's  patient,  how- 
ever, was  still  living  four  years  after  operation  without  any  return  of 
the  disease. 

While  it  must  be  admitted  that  these  statistics  are  the  worst  con- 
ceivable, and  that  the  prospects  of  success  are  very  slight,  it  must 
not  be  forgotten  that  even  without  operation  the  patient  is  sure  to  die. 
In  view  of  our  improved  technic  in  operation  for  hypertrophy  of  the 
prostate,  such  as  the  introduction  of  the  prerectal  incision,  and  such 
procedures  as  Fritz  Koenig's  operation  for  removal  of  carcinoma  of 


PLATE  X. 


A.   Prostate  separated  from  surrounding  structures  except  posteriorly 


1 

yi^N^ 

fe\ 

Dkr  ^ 

*£■ —    | 

mB 

\ 

B.  Prostate  completely  freed  and  drawn  well  out  into  the  wound      (Young.) 


PLATE  XI. 


C.  Bladder  incised  at  prostato-vesical  junction. 


D.    Vesical    incision    continued.     Trigone    exposed.    The    dotted  line    marks    the 
incision  across  it.     (Young.) 
27 


PLATE  Xll. 


E.     Base  of  bladder  pushed  upwards  exposing  anterior  surface  of  seminal  vesicles 
and  vasa  deferentia. 


F.     Showing  anastomosis  between  the  membranous  urethra  and  bladder,  and  the 
sutures  passed  through  the  margins  of  the  vesical  wound.     (Young.) 


NEW    GROWTHS    OF    THE    PROSTATE.  399 

the  rectum,  hope  should  not  be  entirely  abandoned,  but  further  efforts 
should  be  made  to  completely  remove  the  neoplasm. 

[Young,  of  Baltimore,  has  recently  reported  four  cases  in  which  he 
removed  the  entire  prostate,  the  seminal  vesicles,  the  vasa  deferentia 
and  most  of  the  trigonum. 

Dr.  Young  describes  his  operation  practically  as  follows: 

The  prostate  is  exposed  as  in  the  operation  of  perineal  prostatec- 
tomy. The  handle  of  the  retractor  is  then  depressed  so  as  to  expose 
the  membranous  urethra,  -which  is  then  divided  transversely.  By 
further  depressing  the  handle  of  the  tractor  the  pubo-prostatic  liga- 
ment is  exposed,  and  is  divided  with  scissors,  thus  completely  sever- 
ing the  prostate  from  all  important  attachments  except  posteriorly,  as 
shown  in  Plate  X,  A.  The  lateral  attachments  are  then  separated 
by  the  fingers. 

The  posterior  surface  of  the  seminal  vesicles  is  then  freed  by 
blunt  dissection,  the  now  mobile  prostate  being  well  out  of  the  wound, 
as  shown  in  Plate  X,  B.  In  exposing  the  posterior  surface  of  the 
vesicles  care  must  be  taken  not  to  break  through  the  fascia  of  Denon- 
villiers,  which  covers  the  posterior  surface  of  the  prostate  and  seminal 
vesicles,  and  which  undoubtedly  forms  an  important  barrier  to  the 
backward  growth  of  the  disease. 

The  next  step  is  to  expose  the  anterior  surface  of  the  bladder  by 
still  further  depressing  the  tractor  and  making  strong  traction.  The 
bladder  is  then  incised  at  a  point  in  the  middle  line  about  i  cm.  be- 
hind the  prostato- vesical  junction  (Plate  XI,  C).  The  dissection  is 
then  continued  on  each  side  with  scissors  until  the  trigone  is  exposed. 
The  trigone  is  then  incised  transversely  about  i  cm.  in  front  of  the 
ureteral  orifices.     (Plate  XI,  D.) 

While  still  making  traction  upon  the  prostate,  the  base  of  the 
bladder  is  pushed  upward  so  as  to  expose  the  anterior  surface  of  the 
seminal  vesicles  and  the  adjacent  vasa  deferentia  (Plate  XII,  E),  all 
of  which  are  carefully  freed  by  blunt  dissection  with  the  finger  as 
high  up  as  possible,  so  as  to  remove  with  the  vesicles  the  circumjacent 
fat  and  areolar  tissues  on  account  of  the  lymphatics  which  they  con- 
tain. The  vasa  deferentia  are  divided  as  high  up  as  possible,  care 
being  taken  to  see  that  the  ureters  are  not  cut  with  them. 

An  anastomosis  is  then  made  between  the  bladder  and  membranous 
urethra  and  the  remainder  of  the  vesical  wound  closed.  (Plate  XII, 
F.)     The  first  suture  is  placed  by  inserting  the  needle  into  the  tri- 


400  DISEASES    OF    THE    PROSTATE    GLAND. 

angular  ligament  above  the  urethra  and  out  through  the  anterior  wall 
of  the  bladder  in  the  median  line,  from  within  out,  care  being  taken 
to  include  only  the  submucosa  and  muscle.  When  this  suture  is  tied, 
the  median  line  of  the  anterior  wall  of  the  bladder  is  drawn  to  meet 
the  urethra,  the  knot  outside,  and  the  thread  left  long. 

Lateral  sutures,  similarly  placed  (including  the  periurethral  muscu- 
lar structures  below),  and  two  posterior  sutures  complete  the  anas- 
tomosis of  the  membranous  urethra  with  a  small  ring  into  wrhich  the 
anterior  portion  of  the  margin  of  the  vesical  wound  has  been  fash- 
ioned by  the  tying  of  the  sutures. 

It  is  most  interesting  to  note  that  the  functional  results  after  this 
extensive  operation  were  good. 

One  patient  died  at  the  end  of  six  weeks,  death  being  attributed  to 
the  removal  of  the  valvular  ends  of  the  ureters,  owing  to  the  belief 
that  they  were  involved  in  the  malignant  process;  one  patient  died 
at  the  end  of  a  year  as  the  result  of  a  stone-crushing  operation ;  the 
other  cases  were  too  recent  for  consideration,  six  and  two  months 
respectively  having  elapsed  between  the  date  of  operation  and  the 
time  the  report  was  made.*] 

SYPHILIS  OF  THE  PROSTATE. 

From  the  circumstance  that  I  have  not  met  with  a  single  positive 
case  of  syphilis  among  a  large  number  of  diseases  affecting  the  prostate 
I  am  led  to  conclude  that  its  occurrence  is  exceedingly  rare.  More- 
over, only  a  few  cases  are  mentioned  in  literature  which  may  possibly 
have  been  true  cases  of  lues  of  the  prostate.  These  have  been  reported 
by  Reliquet,  Rochon,  Wroszynski,  and  Grosligk.  Grosligk's  case  is 
the  one  in  which  there  is  the  greatest  probability  that  the  lesion  in 
question  was  a  gumma. 

This  case  was  that  of  a  man  aged  forty-five  who  complained  of 
painful  and  urgent  urination  and  tenderness  in  the  perineum.  He 
had  had  gonorrhoea  a  long  time  before,  but  had  been  cured  of  it  and 
had  remained  perfectly  well.  There  was  a  scanty  brownish  urethral 
discharge  containing  pus-cells  and  erythrocytes,  but  no  gonococci. 
A  t  9  French  sound  was  passed  without  difficulty.     Upon  rectal  exami. 

*  Since  the  publication  of  the  first  edition  of  this  book  two  other  patients  have 
been  operated  on.  Of  six,  the  total  number  upon  whom  the  operation  was  per- 
formed, two  were  well  and  apparently  free  from  recurrence  January  i,  1908, 
nearly  three  years  after  they  were  operated  upon. 


PARASITES  OF  THE  PROSTATE.  401. 

nation  the  prostate  was  found  to  be  as  large  as  a  man's  fist,  uneven, 
of  the  consistency  of  cartilage,  and  sensitive  to  pressure.  These 
findings  naturally  aroused  the  suspicion  of  carcinoma,  and  this  sus- 
picion was  strengthened  by  the  patient's  denial  of  syphilis.  Later, 
however,  he  admitted  having  had  the  disease,  and  energetic  antisyph- 
ilitic  treatment  was  begun,  with  the  result  that  in  four  weeks  all  signs 
of  the  tumor  and  all  subjective  symptoms  had  disappeared.  In  course 
of  time  the  prostate  enlarged  again  simultaneously  with  the  occurrence 
of  a  syphilitic  affection  of  the  neck;  both  lesions  subsided  under  anti- 
luetic  treatment. 

This  carefully  observed  case  must  be  taken  into  account,  and  in 
cases  of  prostatic  inflammation  in  which  there  is  no  determinable 
cause  it  should  direct  our  attention  to  the  possibility  of  syphilitic 
disease. 

Above  all  this  case  teaches  us  to  be  careful  in  making  a  diagnosis 
of  cancer.  In  dealing  with  cases  of  prostatic  tumor  in  which  the 
origin,  nature,  rapid  growth,  and  findings  upon  palpation  are  in  any- 
wise suspicious,  and  especially  if  other  known  signs  of  syphilis  are 
demonstrable,  antisyphilitic  treatment  may  be  tried  after  all  the  other 
means  of  diagnosis  have  been  exhausted. 

PARASITES  OF  THE  PROSTATE. 

The  echinococcus  is  the  only  parasite  requiring  consideration,  and  it 
is  doubtful  if  the  cases  reported  as  such  were  cases  of  true  echinococcus 
disease,  or  whether  they  were  cases  in  which  the  echinococcus  had 
taken  up  its  abode  in  the  tissues  and  grown  into  the  prostate.  In  the 
space  between  the  bladder  and  rectum  echinococcus  cysts  have  been 
repeatedly  found.  Of  cases  which  have  been  carefully  observed, 
and  some  of  which  have  been  studied  postmortem,  we  will  mention 
three  which  best  illustrate  the  development  and  symptoms  of  the 
affection. 

In  one  case,  that  of  Maunder,  and  which  I  take  from  Englisch's 
description,  a  man  twenty-four  years  old  was  attacked  with  retention 
of  urine,  which  lasted  four  days.  The  region  above  the  symphysis, 
up  as  high  as  the  umbilicus,  was  much  distended  by  a  spherical  tumor, 
which  upon  pressure  was  sensitive  and  plainly  showed  signs  of  fluctu- 
ation. This  fluctuating  mass  could  be  plainly  felt  through  the  rectum, 
through  which  it  was  punctured,  and  a  liter  of  clear  serous  fluid  obtain- 


4<D2  DISEASES    OF    THE    PROSTATE    GLAND. 

ed.  This  fluid  contained  no  formed  elements.  While  it  was  being 
discharged  a  large  quantity  of  high-colored  urine  was  passed  through 
the  urethra.  Two  days  later  the  patient  died  of  peritonitis.  Autopsy 
revealed  a  healthy  bladder,  but  in  the  space  between  the  bladder  and 
the  rectum  an  empty  sac  was  found  which  plainly  showed  a  punctured 
opening.  Hydatid  cysts  were  found  here  and  there  on  the  abdominal 
viscera,  and  a  large  one  was  present  in  the  inguinal  canal,  resembling 
a  reducible  inguinal  hernia. 

A  second  case,  reported  by  Lowdell,  was  that  of  a  man  aged  sixty- 
four  who  had  for  several  years  complained  of  difficulty  in  voiding 
his  urine,  and  finally  came  to  be  affected  with  complete  retention. 
Postmortem  examination  revealed  a  much  thickened  bladder.  In 
place  of  the  prostate  there  was  a  tumor  the  size  of  a  child's  head, 
which  upon  being  opened  proved  to  be  a  collapsed  hydatid  cyst.  The 
reticulum  contained  hydatids.  It  is  not  clear  whether  this  hydatid 
cyst  developed  in  the  prostate  or  whether  it  originated  without  the 
gland  and  caused  atrophy  of  the  latter  by  pressure. 

Spence's  case  is  very  instructive.  It  is  that  of  a  man  aged  fifty- 
five,  who  had  suffered  from  retention  of  urine  six  months  and  on  whom 
catheterization  had  often  been  unsuccessfully  tried.  Examination 
revealed  a  tumor  in  the  recto-vesical  space.  In  the  right  hypochon- 
drium  a  large  tumor  had  developed  without  any  signs  of  inflammation. 
Catheterization  was  tried  again;  it  was  successful  and  a  large  quantity 
of  urine  was  voided,  but  the  tumor  remained  unaltered.  It  was  then 
punctured  with  an  ordinary  trocar  and  a  large  quantity  of  clear  fluid 
rich  in  hydatids  was  obtained.  Discharge  of  fluid  through  the  punc- 
ture continued  for  two  weeks.  During  severe  straining  at  stool  the 
cyst  ruptured  and  discharged  a  large  number  of  hydatids  into  the 
rectum.  Suppuration  of  the  cyst  followed  and  healing  took  place, 
so  that  a  thickened  area  on  the  anterior  wall  of  the  rectum,  around 
the  site  where  puncture  had  been  made,  remained.  The  tumor  in  the 
hypochondrium,  however,    grew  very  rapidly. 

From  the  history  of  these  cases,  for  which  I  am  indebted  to  the 
careful  researches  of  Englisch — echinococcus  disease  of  the  prostate 
being  very  rare,  so  that  I  have  not  had  the  opportunity  of  observing 
any  cases  myself — it  will  be  seen  that  urinary  disturbances  character- 
ize the  disease.  Micturition  is  interfered  with  for  a  long  time,  and 
therapeutic  measures  have  no  effect  upon  the  trouble.  Finally  com- 
plete retention  occurs. 


NEUROSES    OF    THE    PROSTATE.  403 

Upon  examination  a  tumor  will  be  detected,  generally  one  of  large 
size,  which  is  palpable  through  the  rectum,  and  also  can  often  be 
felt  upon  bimanual  examination  over  the  symphysis.  The  tumor 
fluctuates  and  is  characterized  by  its  size.  If  the  patient  be  catheter- 
ized  the  tumor  remains  unaffected,  a  sign  which  shows  that  it  was 
not  an  over-distended  bladder  which  was  felt.  Exploratory  puncture 
with  subsequent  aspiration  will  confirm  the  diagnosis  by  revealing 
scolices,  single  hooklets,  or  stratified  pieces  of  membrane.  More- 
over, it  is  worthy  of  mention  that  other  cysts  as  large  as  those  produced 
by  echinococci  are  not  found  in  the  space  between  the  bladder  and 
rectum,  so  that  the  presence  of  a  large  cyst  in  this  locality  should  of 
itself  give  rise  to  strong  suspicion  of  echinococcus  disease. 

Treatment  is  entirely  surgical  and  will  be  determined  somewhat 
according  as  other  cysts  are  or  are  not  present.  Puncture,  incision, 
and  enucleation  of  the  sac  through  a  prerectal  incision  are  the  pro- 
cedures to  be  employed.  [It  seems  to  me  that  large  cysts  could  be 
removed  easier  by  the  suprapubic  route  than  through  the  perineum.] 

NEUROSES  OF  THE  PROSTATE. 

The  term  prostatic  neurosis  has  been  applied  to  a  series  of  nervous 
sexual  disturbances  in  which  the  prostate  shares  in  the  trouble,  although 
it  is  not  exclusively  affected.  This  class  of  cases  will  be  discussed 
under  sexual  neurasthenia,  whereas  here  we  shall  confine  ourselves 
to  the  genuine  neuroses  of  the  prostate. 

In  the  prostate,  which  is  so  richly  supplied  with  nervous  elements, 
we  meet  with,  according  to  Peyer,  three  kinds  of  nervous  disturbances : 
hyperassthesia  of  the  gland  itself;  hyperesthesia  of  the  prostatic  urethra; 
nervous  irritability  of  the  muscular  portion  of  the  gland,  which  in 
part  constitutes  the  sphincter  of  the  bladder. 

These  three  conditions  seldom  occur  distinct  and  alone,  but  are 
found  in  association  with  one  another,  or  one  merges  into  the  other, 
so  that  the  symptoms  of  one  form  are  more  prominent  at  one  time  and 
the  symptoms  of  another  form  advance  to  the  fore  at  another  time. 

Prostatic  neuroses  affect  young  persons,  as  a  rule,  an  occurrence 
which  is  doubtlessly  explained  by  the  fact  that  they  usually  follow 
inflammatory  processes  in  the  urethra,  that  is  to  say,  chronic  gonor- 
rhoea, which  either  involved  the  prostate  at  an  early  stage  of  its 
evolution  or  extended  to  it  through  the  prostatic  ducts  at  a  later 
period. 


404  DISEASES    OF    THE    PROSTATE    GLAND. 

Although  the  majority  of  prostatic  neuroses  have  their  origin  in 
this  manner,  yet  I  have  seen  many  cases  in  persons  who  had  never  had 
any  venereal  disease.  For  the  most  part  they  occurred  in  neuro- 
pathic persons  who  had  masturbated  excessively  for  years,  and  who 
had  not  been  in  the  habit  of  having  sexual  intercourse,  either  for  the 
reason  that  they  were  impotent  or  thought  themselves  to  be.  Then 
there  was  a  series  of  cases  in  persons  who  had  led  a  very  active  sexual 
life,  and  finally  another  in  the  subjects  of  general  neurasthenia,  whose 
trouble,  though  due  to  exacting  mental  application  or  overwork, 
assumed  the  form  of  sexual  neurasthenia  with  symptoms  referable 
to  the  prostate. 

The  symptom-complex  of  the  prostatic  neuroses  is  especially  char- 
acterized by  absence  of  objective  signs  of  inflammation  in  the  sexual 
organs,  or  by  manifestations  so  slight  that  they  do  not  suffice  to  explain 
the  severe  symptoms  complained  of. 

The  general  hyperesthesia  of  the  organ  is  well  shown  by  a  constant 
feeling  of  pain  and  heaviness,  which  at  times  becomes  exacerbated  and 
gives  the  physician  the  impression  that  he  has  to  do  with  an  acute 
prostatitis.  Palpation  and  examination  of  the  prostatic  secretion 
show  the  error  of  such  a  view.  To  be  sure,  the  gland  is  very  sensi- 
tive to  pressure,  but  the  swelling  present  in  acute  inflammation  is 
wanting.  Occasionally  a  few  white  cells  are  found  in  the  secretion  as 
the  expression  of  a  previous  inflammation,  but  this  is  quite  a  different 
thing  from  finding  a  secretion  composed  almost  entirely  of  pus-cells 
and  erythrocytes,  such  as  is  found  in  acute  catarrh  of  the  prostate. 
Furthermore  difficulty  of  micturition  is  absent  in  this  form  of  prostatic 
neurosis,  but  is  always  present  in  extensive  acute  inflammatory  disease; 
the  urine  also  is  clear  and  perfectly  normal  in  other  respects. 

In  those  cases,  too,  in  which  the  neurosis  affects  the  prostatic  urethra 
more  than  it  does  the  prostate  gland  itself  there  are  likewise  no  demon- 
strable objective  changes  either  in  the  urethra  or  in  the  urine.  The 
urine  is  clear  and  free  from  abnormal  elements,  except  perhaps  for 
the  presence  of  a  few  filaments,  which  represent  the  remnants  of  a 
previous  catarrh  that  may  have  supplied  the  cause  for  the  development 
of  the  neurosis.  There  is  no  explanation  for  the  pain  which  is  expe- 
rienced during  micturition.  Upon  palpation  the  gland  is  found  of 
normal  size  and  not  excessively  tender. 

If  a  sound  is  introduced  into  the  urethra,  however,  the  patient 
grows  faint  with  pain  as  soon  as  the  instrument  enters  the  prostatic 


NEUROSES    OF    THE    PROSTATE.  405 

portion.  I  place  no  reliance  upon  apparent  anatomical  changes  in 
this  portion  of  the  urethra  as  shown  by  the  urethroscope,  because 
I  am  of  the  opinion  that  they  cannot  be  distinguished  from  such  as 
might  artificially  be  produced  by  the  introduction  of  the  instrument. 
For  this  reason  it  is  better  to  spare  the  annoyance  of  such  an  exami- 
nation, which,  moreover,  can  result  only  in  harm. 

The  third  form  of  prostatic  neurosis,  which  is  characterized  by 
spasm  of  the  sphincter,  and  the  detrusor  vesicas  as  well,  is  the  one 
most  frequently  met  with.  The  spasm  of  the  sphincter  is  shown  by 
the  difficulty  with  which  the  patient  urinates;  the  tonicity  of  the  mus- 
cle, which  under  ordinary  circumstances  readily  yields  to  the  contrac- 
tions of  the  detrusor,  is  increased. 

In  the  mildest  grade  of  this  neurosis  the  patients  cannot  urinate  in 
the  presence  of  others,  but  when  they  are  alone  they  regain  control  over 
the  sphincter.  When  the  neurosis  is  more  pronounced  the  disturbance 
of  micturition  is  more  severe.  The  patients  are  obliged  to  strain 
and  call  the  action  of  abdominal  pressure  into  play  before  they  can 
get  any  urine  out  of  the  bladder.  The  stream  is  small  at  first,  without 
force,  and  often  interrupted,  as  though  a  small  calculus  had  cut  it  off. 
When  it  once  becomes  established  and  the  urine  flows  out  more  freely 
a  burning  sensation  is  felt  in  the  urethra  near  the  end  of  the  penis. 
If  a  catheter  be  passed  into  the  bladder  after  the  patient  has  urinated, 
more  or  less  residual  urine  will  be  found,  a  fact  which  shows  that 
the  bladder  has  not  completely  emptied  itself. 

All  these  phenomena  resemble  those  which  are  found  in  association 
with  some  real  impediment  at  the  neck  of  the  bladder.  They  differ 
from  the  latter,  however,  in  the  following  respects :  they  are  not  con- 
stant, being  present  at  one  time  and  absent  at  another;  the  quantity 
of  residual  urine  may  vary  considerably ;  the  urethra  is  not  lengthened 
as  it  is  in  prostatic  hypertrophy;  catheterization  is  easy  unless  a  fine- 
pointed  instrument  is  used.  Fine-pointed  instruments  are  ill-adapted 
to  the  purpose  because  the  point  becomes  caught  and  firmly  held  by 
the  sphincter.  Large  cylindrical  sounds  and  catheters,  especially 
metal  ones,  which  cannot  be  bent,  generally  overcome  the  resistance 
at  once.  It  is  not  necessary  to  lower  the  instrument  as  much  as  in 
hypertrophy  of  the  prostate.  This  condition  is  distinguished  from 
stricture  by  the  distance  of  the  obstruction  from  the  external  meatus ; 
as  is  well-known,  strictures  are  almost  never  present  near  the  neck  of 
the  bladder. 


406  DISEASES    OF    THE    PROSTATE    GLAND. 

The  spasm  of  the  detrusor,  also  called  vesical  spasm  for  short,  is 
characterized  by  the  fact  that  the  patient  has  occasional  attacks  of 
strangury  for  which  no  objective  basis  can  be  found.  This  urgency 
of  micturition  is  not  constant,  as  it  is  in  inflammatory  conditions,  but 
it  comes  on  suddenly,  then  disappears  and  remains  absent  for  a  long 
time.    It  is  never  present  at  night. 

Micturition  is  painless,  and,  as  a  rule,  the  urine  is  voided  without 
difficulty.  The  urine  is  clear  and  contains  no  abnormal  elements. 
Any  mental  or  sexual  excitement  increases  this  strangury,  but  no 
cause  for  its  origin  can  be  found. 

The  first  as  well  as  the  last  form,  both  spasm  of  the  sphincter  and 
of  the  detrusor,  is  often  the  sequel  of  a  previous  gonorrhoea  and  pros- 
tatitis, but  they  are  also  met  with  in  persons  who  never  had  these 
diseases.  It  has  already  been  stated  that  all  of  these  neuroses  may 
merge  one  into  another,  or  be  combined. 

The  course  is  of  long  duration,  and  characterized  by  periods  of 
months  or  years  in  which  the  patient  is  free  from  all  difficulty,  until, 
for  some  reason  or  other,  the  old  trouble  makes  its  appearance 
again. 

The  effect  of  treatment  is  as  a  rule  satisfactory,  although  there  are 
cases  which  resist  all  therapeutic  measures.  If  signs  of  previous 
inflammatory  and  suppurative  processes  are  found,  their  successful 
treatment  will  exert  a  very  favorable  effect  upon  the  neurosis.  In 
general  it  may  be  stated  that  the  obstinacy  of  the  symptoms  is  due, 
as  it  also  is  in  other  neuroses,  to  the  fact  that  the  patients  believe 
their  condition  to  be  worse  than  it  really  is. 

In  the  class  of  cases  just  referred  to  they  believe  that  the  filaments 
in  the  urine,  the  sense  of  pressure  at  the  anus,  and  the  pain  upon  mic- 
turition are  signs  of  serious  disease.  If  these  objective  manifestations 
of  their  trouble  can  be  removed,  the  neurasthenic  symptoms  will  be 
considerably  ameliorated,  or  often  entirely  overcome.  Therefore,  in 
such  cases,  judiciously  conducted  local  treatment  will  often  be  of  great 
advantage.  It  consists,  as  has  already  been  stated  in  reference  to 
the  treatment  of  these  inflammatory  conditions,  in  massage  of  the 
prostate,  cauterization  of  the  urethra,  irrigations,  and  the  use  of 
sounds. 

There  are  cases,  however,  in  which  these  m  easures  cannot  be  em- 
ployed without  causing  pain,  and  when  this  happens  the  reverse  is 
the  result:  the  patients  are  made  worse  than  they  were  before,  the 


NEUROSES    OF    THE    PROSTATE.  407 

pain  to  which  they  are  subjected  increasing  their  nervousness.  It  is 
evident  that  in  this  latter  class  of  cases  local  treatment  must  not  be 
resorted  to.  In  other  cases  also  it  should  not  be  carried  too  far,  espe- 
cially if  it  becomes  apparent  that  the  remains  of  the  urethritis  and 
prostatitis  cannot  be  removed,  as  very  often  happens. 

I  can  warmly  recommend  other  local  measures  directed  solely 
against  the  neurosis.  To  this  class  belongs  electrization  of  the  prostate 
and  bladder,  winch  is  performed  by  inserting  one  pole  into  the  rectum 
and  placing  the  other  over  the  symphysis.  The  interrupted  and  con- 
stant current  are  of  equal  value.  The  use  of  the  psychrophore,  or 
my  rectal  thermophore,  has  an  excellent  effect.  In  addition,  baths, 
massage,  exercise,  and  regulation  of  the  diet  should  be  ordered. 
Sitz-baths  at  a  temperature  of  35°C.  increased  to  42°C.  [q8°F.  to  103. 50 
F.],  or  reduced  to  25°C.  [9o°F.],  cold  douches  to  the  perineum,  the  cold 
rub,  exercise  in  the  open  air,  walking,  and  medical  gymnastics  are  all 
indicated. 

To  overcome  spasm  of  the  sphincter  a  large  sound  may  be  passed 
and  left  in  place  for  a  short  time.  Belladonna,  either  internally  or  in 
the  form  of  suppositories  or  rectal  injections,  may  also  prove  of  service. 
Such  nervines  as  sodium  bromide,  tincture  of  gelsemium,  valerian, 
antipyrine  and  phenacetine  should  constitute  our  list  of  drugs  for 
internal  use.  Narcotics  are  to  be  avoided  if  possible.  [The  coal- 
tar  products  should  also  be  used  with  caution.] 

If,  despite  these  measures,  the  disease  persists,  the  patient  may  be 
sent  to  a  sanatorium,  where  the  same  procedures  we  have  mentioned 
will  be  found  to  exert  a  more  powerful  effect. 


408  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 


DISEASES  OF  THE  TESTICLE,  EPIDIDYMIS,  SPERMATIC 
CORD  AND  THEIR  COVERINGS. 

ANATOMY. 

The  scrotum  consists  of  five  layers:  the  cutis,  the  dartos,  the 
cremasteric  fascia,  the  tunica  vaginalis  communis,  and  the  tunica 
vaginalis   propria. 

There  is  a  raphe  in  the  cutis  in  the  median  line  of  the  scrotum. 
The  dartos  is  continuous  posteriorly  with  the  connective  tissue  of  the 
perineum  and  passes  anteriorly  into  the  root  of  the  penis  forming 
a  septum  between  the  two  testicles.  The  cremaster  is  a  continuation 
of  the  lower  fibers  of  the  internal  oblique  and  transversalis  muscles; 
its  delicate  fibers  are  intimately  blended  with  the  tunica  vaginalis 
communis.  The  latter  is  a  continuation  of  the  transversalis  fascia, 
which  covers  the  testicles  and  seminal  vesicles,  and  is  adherent  to  the 
outer  layer  of  tunica  vaginalis  propria. 

The  tunica  vaginalis  propria  is  a  serous  sac  consisting  of  parietal 
and  visceral  layers,  the  former  of  which  is  attached  to  the  tunica 
vaginalis  communis,  while  the  latter  is  closely  adherent  to  the  testicle, 
covering  it  entirely  except  at  its  posterior  border.  The  serous  cavity 
within  the  tunica  vaginalis  propria  extends  upwards  as  far  as  the 
parietal  peritoneum  in  the  form  of  a  funiculus,  which  represents  the 
remains  of  the  connection  that  existed  during  fcetal  fife  between  the 
tunic  and  the  peritoneum. 

The  testicle  at  its  superior  border  is  overlapped  by  the  head  of  the 
epididymis;  it  is  covered  by  the  tunica  albuginea,  the  outer  surface  of 
which  is  in  relation  with  the  tunica  vaginalis  propria.  The  tunica 
albuginea  sends  septa  into  the  substance  of  the  gland  which  divide 
it  into  a  number  of  lobules,  the  ducts  of  which  meet  in  the  rete  vascu- 
losum  Halleri  and  perforate  the  thickened  portion  of  the  albuginea 
known  as  the  body  of  Highmore  [or  mediastinum  testis]. 

The  epididymis  has  a  thick  anterior  part  known  as  the  head  [globus 
major]  and  a  slender  posterior  portion,  called  the  tail  [globus  minor]. 
It  consists  of  a  narrow  tube  made  up  of  many  complex  coils  which 
originate  from  the  efferent  ducts  in  the  rete  vasculosum  Halleri  and 
end  in  the  vas  deferens. 


PLATE  XIII. 


Testicle  and  spermatic  cord.     Anterior  view.     (Deaver.) 


CONGENITAL    DISEASES    OF    THE    SCROTUM    AND    TESTICLES.       409 

The  spermatic  cord  is  composed  of  the  vas  deferens  and  its  accom- 
panying vessels  and  nerves ;  it  runs  through  the  inguinal  canal,  curves 
over  the  horizontal  ramus  of  the  os  pubis  and  winds  around  the  epi- 
gastric artery,  crosses  the  external  iliac  vessels  and  unites  at  the  base 
of  the  prostate  with  the  duct  of  the  seminal  vesicle  to  form  the  ejacu- 
latory  duct.  In  relation  to  the  other  structures  of  the  cord  it  lies 
posteriorly  and  externally.  It  can  be  felt  through  the  integument 
as  a  smooth,  firm  cord,  and  is  easily  distinguished  from  the  vessels 
and  nerves. 

The  arteries  of  the  spermatic  cord  are  the  spermatic,  the  artery 
of  the  vas  deferens,  and  the  cremasteric.  The  spermatic,  which  is  a 
branch  of  the  abdominal  aorta,  supplies  the  testicle  and  the  epididymis; 
the  artery  of  the  vas  deferens  is  derived  from  the  superior  vesical, 
supplies  in  part  the  tunica  vaginalis  communis  and  the  cremaster,  and 
anastomoses  with  the  spermatic;  the  cremasteric  is  the  principal 
artery  of  the  cremaster;  it  anastomoses  with  the  other  arteries  of  the 
cord. 

As  the  veins  of  the  testicle  ascend  into  the  cord  they  form  a  network 
known  as  the  pampiniform  plexus,  from  which  the  spermatic  veins 
originate.  The  right  spermatic  vein  empties  directly  into  the  vena 
cava,  the  left  one  into  the  left  renal  vein.  The  lymphatics  of  the  cord 
empty  into  the  lymph-glands  of  the  pelvis. 

The  nerves  also  form  a  plexus,  which  is  known  as  the  spermatic 
plexus;  they  are  derived  partly  from  the  lumbar  plexus  and  partly 
from  the  sympathetic. 

The  scrotum  is  supplied  by  the  artery  of  the  septum,  which  comes 
from  the  internal  pudic,  and  by  the  external  pudic,  a  branch  of  the 
femoral.  The  lymph- vessels  empty  into  the  superficial  inguinal 
glands.  The  nerves  are  derived  from  the  internal  pudic,  the  external 
spermatic,  and  the  posterior  femoral  cutaneous. 

THE    CONGENITAL   DISEASES    OF   THE   SCROTUM   AND 

TESTICLES. 

Occasionally  the  scrotum  is  divided,  each  testicle  lying  in  a  separate 
compartment  surrounded  by  its  own  coverings.  This  anomaly  causes 
the  scrotum  to  resemble  somewhat  the  labia  majora  of  the  female. 
The  testicles  in  these  separate  compartments  may  be  perfectly  normal. 
The  condition  is  caused  solely  by  a  separation  of  the  two  organs  which 
took  place  in  fcetal  life. 
28 


4IO  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

A  more  frequent  congenital  anomaly  is  rudimentary  development 
or  complete  absence  of  the  testicles  and  their  adnexa  (hypoplasia  or 
atrophy,  and  aplasia  or  anorchism).  Usually  the  abnormality  is 
unilateral.  Microscopically  such  atrophic  testicles  show  either  the 
structure  of  the  infantile  organ,  that  is,  a  rich  connective  tissue  stroma, 
and  absence  of  spermatozoa  in  the  seminal  tubules,  or  else  they  con- 
sist almost  entirely  of  connective  tissue  through  which  masses  of  fat 
are  distributed,  but  in  which  no  seminiferous  tubules  are  contained. 

Much  more  frequent  than  any  of  these  abnormalities  is  excessive 
development  of  the  testicle,  known  as  hypertrophy  or  hyperplasia. 
Although  it  is  usually  unilateral,  occurring  in  association  with  absence 
or  atrophy  of  the  opposite  organ,  it  may  be  bilateral. 

When  the  position  of  the  testicle  is  abnormal,  the  condition  is  known 
as  inversio  testis ;  it  may  be  either  vertical  or  horizontal,  according  to 
the  axis  upon  which  it  is  rotated ;  the  rotation  may  be  either  complete 
or  partial.  The  causes  of  this  abnormality  are  not  known.  Le  Dentu 
attributes  it  to  faulty  attachment  of  the  gubernaculum  testis. 

Cases  in  which  the  testicle  does  not  descend  into  the  scrotum  are 
known  by  the  name  of  ectopia  testis.  When  it  lies  under  the  skin  of 
the  abdomen  the  condition  is  spoken  of  as  ectopia  abdominalis;  when 
in  the  region  of  the  thigh  as  ectopia  cruralis.  It  may  also  be  found  in 
the  perineum,  in  which  case  the  condition  is  called  ectopia  perinealis. 

RETENTION  OF  THE  TESTICLE. 

Of  greater  practical  importance  than  the  abnormalities  thus  far 
mentioned  is  retention  of  the  testicle,  a  condition  in  which  the  testicle 
does  not  descend,  but  remains  in  the  abdomen  or  is  arrested  in  some 
portion  of  its  passage  downward.  [This  condition  must  not  be  con- 
founded with  ectopia  testis,  which  is  a  displacement  of  the  organ.] 

Before  the  testicle  descends  from  its  embryonal  bed  within  the 
abdomen,  through  the  inguinal  canal  into  the  scrotum,  the  peritoneum 
surrounding  it  anteriorly  and  laterally  projects  itself  downwards, 
so  that  when  the  testicle  reaches  the  scrotum  there  is  a  sac-like  process 
of  peritoneum  extending  from  the  internal  abdominal  ring  above 
to  the  gland  below.  This  diverticulum  is  known  as  the  vaginal  process 
of  peritoneum.  Normally  its  walls  grow  together  so  that  it  becomes 
obliterated  and  forms  a  fibrous  cord.  The  process  of  peritoneum 
covering  the  testis  itself  forms  the  tunica  vaginalis  propria. 

Under  normal  conditions  the  descent  of  the  testis  ends  when  it  reaches 


PLATE    XIV 


CHRONICALLY    INFLAMED    TESTICLE    REMOVED    FROM    THE    ABDOMEN. 
TORSION   OF  THE  CORD  AND   H/EMORRHAGE  HAD   OCCURRED 
(DRAWING    FROM   A    SPECIMEN   PRESENTED  TO  THE 
EDITOR    BY    DR.    L.    W.    STEINBACH.l 


RETENTION    OF    THE    TESTICLE.  411 

the  scrotum.  If  its  descent  is  arrested  and  it  remains  fast  in  some 
portion  of  its  course,  a  condition  known  as  relentio  testis  is  produced. 
The  testicle  may  remain  in  the  abdomen,  or  be  arrested  in  the  inguinal 
canal.  If  the  retention  is  unilateral  the  condition  is  known  as  monor- 
chism, if  bilateral  as  cryptorchism.  The  cause  of  these  conditions  is 
an  arrest  of  development,  which  may  be  due  either  to  hereditary 
influences  or  to  fortuitous  conditions  such  as  peritoneal  adhesions. 

The  diagnosis  is  not  difficult;  one  side  of  the  scrotum  is  empty, 
and  in  case  of  inguinal  retention  the  testicle  can  be  felt  in  the  inguinal 
canal.     If  it  is  in  the  abdomen,  on  the  contrary,  it  is  not  palpable. 

For  various  reasons  a  certain  importance  is  attached  to  this  abnormal 
situation  of  the  testis.  The  retained  testicle,  particularly  when  arrested 
in  the  inguinal  canal,  often  atrophies;  it  often  becomes  the  seat  of 
inflammation  owing  to  the  pressure  to  which  it  is  subjected,  or  to  the 
effects  of  gonorrhoea.  Kocher  has  observed  that  retained  testicles 
often  become  carcinomatous,  and  Kcenig  confirms  this  observation. 
For  this  reason  alone  it  is  apparent  how  important  the  diagnosis  and 
correction  of  this  abnormality  is.  [Sarcomatous  degeneration  may 
also  take  place.  I  have  known  a  testicle  retained  within  the  abdomen 
to  undergo  cystic  degeneration,  and  in  another  case  to  become  very 
much  inflamed.      (Plate  XIV.)] 

Retention  of  the  testicle  requires  treatment  only  when  the  organ  is 
in  the  inguinal  canal;  when  retained  in  the  abdomen  no  treatment  is 
needed  [unless  it  gives  rise  to  trouble].  [The  possibility  of  its  becoming 
inflamed  or  undergoing  cystic  degeneration  or  malignant  change 
must  be  remembered.]  When  the  gland  is  movable  an  effort  may 
be  made  to  bring  it  down  before  puberty  by  manipulation  and  massage. 
Haidenhain  recommends  drawing  it  down  and  keeping  it  in  place  by 
means  of  a  truss.     [Little  is  to  be  expected  from  such  procedures.] 

Several  surgeons,  among  whom  may  be  mentioned  Julius  Wolf, 
Max  Schuller,  Nicoladoni,  [and  Arthur  D.  Be  van],  have  endeavored 
to  fix  the  testicle  in  the  scrotum  by  operative  procedures.  These  pro- 
cedures are  conservative  and  are  commendable  so  long  as  the  oper- 
ation does  not  endanger  life.  In  case  of  the  latter  event  the  certain 
and  safe  procedure  of  extirpation  is  to  be  recommended.  The  surgeon 
should  not  be  too  loath  to  resort  to  the  latter  operation,  because  the 
testicle  is  commonly  atrophied  and  therefore  is  of  no  use,  and  further- 
more, because,  as  has  been  shown  by  Kocher  and  others,  it  is  liable 
to  undergo  malignant  change. 


412 


TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 


Vaginal process  Itr/oied 


Purse  string 
future  to  form 
a  tunico  Vagi  not  is. 


For  removal  of  the  testicle  from  the  inguinal  canal  an  incision  is  made 
parallel  with  and  about  half  an  inch  above  Poupart's  ligament,  and  the 
gland  freely  exposed.  The  vas  deferens  is  first  isolated,  the  vessels 
ligated  by  a  double  ligature  either  en  masse,  or  better  separately,  and 
the  cord  then  divided.  The  operation  is 
difficult  only  when  the  testicle  is  adherent 
to  a  tumor  or  when  a  hernia  is  present. 
In  the  latter  case  the  peritoneal  cavity 
may  easily  be  opened.  [In  all  cases  in 
which  the  testicle  appears  to  be  normal, 
that  is,  in  which  it  is  neither  atrophied 
nor  inflamed,  nor  subject  to  malignant 
changes,  I  deem  it  conservative  surgery 
to  transplant  the  gland  to  the  scrotum. 

For  this  purpose  Max  Schuller  divided  Fig"  I99'    (Bevan-} 

the  vaginal  process  of  peritoneum  and  stitched  the  testicle  into  the 
scrotum. 

A  more  complete  and  satisfactory  operation  has  been  devised  by 
Arthur  D.  Bevan,  of  Chicago.  It  is  performed  as  follows.  The  tes- 
ticle is  exposed  by  a  three  inch  inci- 
sion over  the  inguinal  canal,  similar  to 
the  one  made  in  Bassini's  hernia  oper- 
ation ;  the  vaginal  process  of  peritoneum 
is  divided  above  the  testis  and  ligated 
just  as  the  neck  of  a  hernial  sac  is 
ligated ;  and  a  tunica  vaginalis  for  the 
testis  then  formed  by  closing  that  por- 
tion of  the  peritoneum  which  sur- 
rounds it  with  a  purse-string  suture. 
(Fig.  199.)  The  testicle  is  now  lifted 
from  its  bed,  the  cord  is  lengthened 
by  making  traction  upon  it,  and  is  en- 
tirely freed  from  connective  tissue,  so 
that  only  the  vas  deferens  and  blood-vessels  remain.  These  structures 
are  separated  from  the  peritoneum  by  introducing  the  finger  into  the 
abdominal  cavity  and  dissecting  them  away.  When  this  has  been  ac- 
complished, a  cavity  is  made  in  the  scrotum  by  blunt  dissection  and  the 
testicle  pulled  down  into  it  and  retained  in  place  by  means  of  a  purse- 
string  suture  run  through  the  neck  of  the  scrotum.      "This  suture 


\Testi  clef  reed  v 
I  and  ready  for 
\    replacement. 

I 


Fig.  200.     (Bevan.) 


CONGENITAL    HYDROCELE. 


413 


_  Spermahc  vesseti' 


Fig.  201.     (Bevan.) 


should  pass  through  the  superficial  fascia  and  the  external  oblique  on 
both  sides ;  that  is,  both  the  internal  and  external  pillars  of  the  external 
ring  and  above  the  cord."  If  the  cord  has  been  properly  freed  in  the 
manner  described,  it  will  be  so  lengthened  that  the  testicle  can  be 
drawn  into  the  scrotum  without  tension.  (Fig.  200.)  When  the  testi- 
cle is  well  up  in  the  abdomen,  or  per- 
haps in  other  exceptional  cases,  this 
method  will  not  suffice  to  free  the 
testicle,  so  that  it  can  be  drawn  down 
without  being  subjected  to  tension;  in 
such  cases  the  spermatic  vessels  are 
ligated  and  divided,  it  being  these 
structures  which  constitute  the  impedi- 
ment to  lengthening.  (Fig.  201.)  The 
artery  of  the  vas  deferens  is  said  to 
afford  sufficient  nourishment  to  the 
testicle.  The  incision  is  closed  as  an 
ordinary  hernia  incision,  with  the  exception,  of  course,  that  the  cord 
is  not  transplanted.] 

CONGENITAL  HYDROCELE. 

When  the  vaginal  process  of  peritoneum  fails  to  close  after  the 
testicle  has  descended,  but  remains  partly  or  entirely  open,  so  that 
the  communication  between  the  peritoneal  cavity  and  the  cavity  of  the 
tunica  vaginalis  persists,  a  congenital  hydrocele  results.  As  the  result 
of  the  connection  betwreen  the  two  the  serous  fluid  of  the  peritoneal 
cavity  can  flow  down  into  the  tunica  vaginalis,  and,  conversely,  the 
fluid  secreted  by  the  tunic  can  gain  access  to  the  abdomen.  The 
passage  between  the  two  cavities  is  usually  very  small. 

The  diagnosis  of  this  condition  rests  upon  the  circumstances  that 
the  tumor  emits  a  dull  percussion  note,  that  it  is  translucent,  that 
it  does  not  glide  back  into  the  abdomen  with  a  gurgling  sound  as 
does  a  hernia,  but  undergoes  reduction  very  slowly  because  of  the 
smallness  of  the  communicating  passage.  If  a  hernia  is  present 
with  the  hydrocele  the  intestine  will  usually  be  found  in  the  upper 
part  of  the  tumor,  the  fluid  in  the  lower. 

Congenital  hydrocele  sometimes  disappears  spontaneously,  the 
fluid  being  resorbed  and  the  funiculus  subsequently  becoming  obliter- 
ated.    If  parietal  adhesions  form  small  serous  cavities  remain  in  the 


414  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

cord  (see  also  under  hydrocele).  If  the  swelling  persists  and  is  in 
any  way  annoying,  the  fluid  may  be  pressed  back  into  the  peritoneal 
cavity  and  a  truss  applied,  or  straps  of  adhesive  plaster  fastened 
around  the  testicle  for  the  purpose  of  lessening  the  size  of  the  opening 
and  causing  its  occlusion.  If  such  measures  fail  the  sac  may  be 
punctured  once  or  repeatedly  with  a  fine  needle.  Usually  the  irritation 
thus  produced  will  bring  about  occlusion.  Only  in  exceptional  cases 
will  it  become  necessary  to  do  one  of  the  radical  operations  which  will 
be  described  later. 

INJURIES    OF    THE    SCROTUM   AND    OF   THE   TESTICLE 
AND  ITS  COVERINGS. 

The  majority  of  injuries  to  the  scrotum  are  bruises  and  lacerations. 
We  distinguish  between  subcutaneous  wounds  and  open  wounds. 
Subcutaneous  wounds  frequently  involve  only  the  coverings  of  the 
testicle,  the  gland  itself  being  uninjured;  even  in  gunshot  wounds  the 
testicle  usually  escapes  the  bullet.  Of  course,  in  any  of  these  injuries 
the  testicle  may  be  involved.  Incised  wounds  of  the  testicle  occur 
almost  always  as  the  result  of  operative  procedures. 

Contusions  of  the  scrotum  are  characterized  by  a  copious  extrava- 
sation of  blood  from  the  numerous  vessels  with  which  the  tissues 
are  supplied.  The  blood  diffuses  itself  extensively  under  the  skin 
and  the  subcutaneous  connective  tissue.  If  the  coverings  of  the 
testicle  and  spermatic  cord  are  affected  the  blood  gravitates  to  the 
net-like  tissue  of  the  tunica  vaginalis  communis  and  forms  a  haema- 
toma. 

This  tumor  differs  from  hematocele,  which  is  a  collection  of  blood 
in  the  cavity  of  the  tunica  vaginalis.  While  haematocele  is  similar  to 
hydrocele,  in  that  it  forms  a  circumscribed  elastic  tumor,  haematoma 
forms  a  more  diffuse  soft  tumor  in  the  scrotum  or  along  the  course  of 
the  spermatic  cord.  If  the  testicle  itself  is  injured  an  effusion  of  blood 
may  occur  within  the  tunica  albuginea  and  form  a  haematoma  testis. 

Although  it  is  of  no  great  practical  importance  to  determine  whether 
the  superficial  layers  of  the  scrotum  alone  or  the  tunics  investing  the 
testicle  are  affected,  it  is  desirable  to  distinguish  these  injuries  from 
injunr  of  the  testicle  itself.  In  contusion  of  the  testicle  the  pain  is 
extreme,  often  being  so  severe  that  the  patient  faints,  or  even  becomes 
profoundly  shocked.     Contusion  of    the    scrotum,  on    the    contrary, 


PLATE    XV 


rORSION    OF  THE   SPERMATIC   CORD.         THE  TWISTED   CORD.   EPIDIDYMIS  AND 

I  !  STICLE   ARE  SEEN   BELOW  THE   REFLECTED   TUNICA  VAGINALIS.  THROUGH 

AN   OPENING   IN   WHICH   THE  STUMP  OF  THE  VIABLE  PORTION   OF  THE 

CORD    IS     VISIBLE.        (E.  ELIOT.   Jr.) 


INJURIES    OF    THE    SCROTUM    AND    TESTICLE.  41 5 

is  not  so  painful,  but  the  extravasation  of  blood  often  assumes  enor- 
mous dimensions,  not  uncommonly  extending  to  the  penis  and  abdomen. 
These  extravasations  of  blood  are  generally  benign.  Under  appro- 
priate treatment  they  become  resorbed.  More  rarely  the  parts  become 
gangrenous.  Subcutaneous  injuries  of  the  testicle  may  pursue  the 
same  course  as  these  wounds,  even  though  at  first  syncope  or  the 
phenomena  of  shock  were  produced.  In  some  cases,  however,  inflam- 
mation of  the  testicle  follows;  it  may  end  in  abscess  formation  or 
atrophy.  The  treatment  of  these  injuries  to  the  scrotum,  the  tunics 
of  the  testicle,  and  of  the  testicle  itself  consists  in  placing  the  injured 
part  at  rest,  elevating  the  penis,  and  applying  lead  water  or  a  solution 
of  aluminum  acetate.  As  a  rule,  the  swelling  and  discoloration  dis- 
appear. Pressure  bandages  for  the  purpose  of  hastening  resorption 
are  contraindicated ;  in  view  of  the  delicacy  of  the  skin  and  the  possi- 
bility of  gangrene  the  utmost  caution  should  be  observed. 

In  case  signs  of  inflammation  appear  and  abscess  is  feared,  the 
parts  must  be  incised,  under  strict  antiseptic  precautions,  so  that  the 
effusion  may  be  liberated.  As  a  rule,  the  development  of  abscess 
and  the  occurrence  of  gangrene  of  the  testicle  is  marked  by  severe- 
constitutional  disturbance,  such  as  chills,  high  fever,  violent  pain,  and 
perhaps  some  mental  hebetude.  In  such  cases  the  parts  should  be 
laid  freely  open  before  the  destructive  process  reaches  the  surface. 
Redness  of  the  skin  and  fluctuation  will  mark  its  advance. 

Gangrene  of  the  testicle  often  follows  subcutaneous  laceration  of 
the  spermatic  cord  and  contusion  or  torsion  of  the  spermatic  artery. 
Swelling  of  the  testicle,  together  with  associated  violent  constitutional 
disturbance,  usually  makes  the  situation  clear.  In  these  cases  we 
should  not  wait  for  atrophy  of  the  testicle  to  take  place,  but  should 
remove  the  gland  at  once. 

[Torsion  of  the  cord  has  been  known  to  occur  as  the  result  of  vio- 
lent sexual  intercourse,  and  has  also  taken  place  without  any  assign- 
able cause. 

In  the  latter  class  of  cases  it  has  been  mistaken  for  strangulated 
hernia.]     (Plate  XV.) 

Finally,  the  testicle  may  be  so  dislocated  by  injuries  which  do  not 
involve  the  skin,  that  it  may  be  pushed  into  the  inguinal  canal,  above 
the  symphysis,  or  into  the  thigh.  Such  a  luxation  of  the  testicle 
must  be  reduced  by  pressure  or  traction,  or  by  operative  means,  for 
the  reason  that  the  gland  may  become  gangrenous. 


41 6  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

OPEN  WOUNDS  OF  THE  SCROTUM  AND  TESTICLES. 

Open  wounds  of  the  scrotum  generally  result  from  contusions,  more 
rarely  from  punctured  or  incised  wounds.  As  already  stated,  the 
testicle  frequently  escapes  injury  in  gunshot  wounds  of  the  scrotum. 
If  the  latter  is  lacerated  or  so  bruised  that  it  bursts,  the  margins  of  the 
wound  usually  retract  so  that  the  testicle  protrudes.  As  dangerous 
as  this  injury  may  appear  the  testicle  generally  retracts  and  the  skin 
comes  together  over  it.  Occasionally  the  testicle  may  become  incar- 
cerated owing  to  retraction  of  the  edges  of  the  wound.  Severe  haem- 
orrhage often  takes  place  from  the  scrotal  wound,  the  edges  of  which 
also  frequently  show  a  tendency  to  become  gangrenous. 

Treatment  is  in  accordance  with  the  established  rules  of  surgery. 
Arrest  of  hasmorrhage,  strict  asepsis,  removal  of  tissue  which  is  so 
crushed  that  it  may  become  gangrenous,  provision  for  drainage,  and, 
finally,  careful  suture  of  the  wound,  are  the  measures  to  be  practised. 

As  concerns  wounds  of  the  testicle,  the  punctured  wounds  usually 
heal  spontaneously.  Incised  wounds,  however,  may  cause  prolapse 
of  the  seminiferous  tubules,  with  the  result  that  they  slough.  If  the 
prolapsed  tissue  can  be  replaced,  the  tunica  albuginea  should  be  care- 
fully sutured  over  it.  If  there  is  danger  of  gangrene  a  timely  castration 
must  be  considered,  as  it  is  important  to  prevent  the  development  of 
phlegmon  or  septicaemia.  The  danger  of  these  complications  is  espe- 
cially great  if  the  albuginea  has  been  sewed  firmly  over  a  prolapsed 
testicle  which  was  already  gangrenous. 

ECZEMA,  (EDEMA,  ERYSIPELAS  AND  PHLEGMON  OF  THE 

SCROTUM. 

The  thin,  delicate  skin  of  the  scrotum,  supplied  as  it  is  with  number- 
less sweat  glands  and  sebaceous  follicles,  is  predisposed  to  erythema 
and  eczema,  diseases  which  are  especially  common  in  summer  among 
fat  persons  of  uncleanly  habits  who  sweat  freely.  Cleanliness,  sup- 
porting the  scrotum  by  means  of  a  suspensory  bandage,  applications 
of  a  2  per  cent  solution  of  aluminum  acetate,  or  oxide  of  zinc  ointment, 
usually  effect  a  rapid  cure. 

(Edema  of  the  scrotum  is  observed  in  dropsy  and  also  occurs  as  the 
result  of  local  circulatory  disturbances.  Compression  with  bandages 
is  to  be  avoided,  because  it  will  increase  the  danger  of  gangrene,  winch 
already  threatens,  owing  to  the  tension  to  which  the  tissues  are  sub- 


TUMORS    OF    THE    SCROTUM    AND    TUNICA    VAGINALIS.  41 7 

jected.  If  the  distension  is  considerable  multiple  punctures  should 
be  made  with  a  sterilized  needle;  this  will  liberate  the  fluid  and  relieve 
tension.     If  the  cause  cannot  be  overcome  the  effusion  will  return. 

Erysipelas  of  the  scrotum  differs  from  the  disease  as  it  affects  other 
parts  of  the  body  in  that  the  characteristic  redness  is  absent,  or  present 
only  in  slight  degree.  It  is  for  this  reason  that  marked  swelling 
terminating  in  gangrene  may  develop  suddenly  and  without  being 
preceded  by  a  preliminary  stage  of  redness.  In  the  same  manner  the 
so-called  spontaneous  gangrene  of  the  scrotum  is  explained,  it  being 
assumed  that  the  preceding  erysipelatous  infection  manifested  itself 
but  little.  Diffuse  gangrene  of  the  scrotum  may  thus  occur  during  the 
course  or  after  the  termination  of  acute  infectious  diseases,  such  as 
typhoid  fever,  small  pox,  pneumonia,  etc. 

Phlegmonous  inflammation  of  the  scrotum  occasionally  follows 
wounds  or  abscesses,  but  it  occurs  much  more  frequently  as  the  result 
of  infiltration  of  urine.  It  produces  violent  disturbances.  The 
scrotum  and  neighboring  tissues,  particularly  the  penis,  are  red, 
swollen,  and  very  sensitive  to  pressure.  The  penis  may  be  cedematous 
throughout  its  entire  length,  and  by  compressing  the  urethra  often  gives 
rise  to  difficulty  of  micturition.  Chills  and  fever  are  also  present. 
Dark  spots  of  varying  size,  the  premonitors  of  gangrene,  appear  on 
the  superficial  tissues.  If  the  phlegmon  soon  opens  the  ragged  gan- 
grenous parts  will  slough  away ;  healing  may  then  take  place,  although 
death  sometimes  results  from  sepsis. 

In  regard  to  treatment,  erysipelas  requires  rest,  elevation  of  the 
parts,  and  the  application  of  antiseptic  dressings;  as  soon  as  the  parts 
become  tense  multiple  scarification  in  the  long  axis  of  the  skin  should 
be  practised.  For  phlegmon  free  deep  incisions  should  be  made 
as  early  as  possible.  The  gangrenous  parts  may  be  left  to  take  care 
of  themselves;  they  will  come  away  spontaneously.  Fever  and  the 
other  constitutional  disturbances  usually  subside  after  surgical  inter- 
vention, and  healing  ensues. 

TUMORS    OF   THE    SCROTUM    AND   TUNICA  VAGINALIS. 

Benign  growths  such  as  lipoma,  fibroma,  angioma,  atheroma  and 
cysts  of  the  scrotum  are  comparatively  rare,  and  when  they  do  occur 
differ  in  no  wise  from  those  in  other  organs  of  the  body. 

A  tumor  peculiar  to  the  scrotum  is  elephantiasis,  which  develops 


41 8  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

under  the  manifestations  of  erysipelatous  inflammation  as  the  result 
of  irritation  produced  by  parasites  (filaria  sanguinis  hominis),  or  other 
causes,  and  which  may  assume  enormous  proportions.  It  seldom 
affects  the  inhabitants  of  the  temperate  zone,  but  occurs  more  fre- 
quently among  those  who  dwell  in  the  tropics,  attacking  both  natives 
and  immigrants.  All  the  elements  of  the  skin  hypertrophy,  but  par- 
ticularly trie  epidermis,  so  that  laceration  easily  takes  place.  Indenta- 
tions alternate  with  protuberances. 

As  to  treatment,  dressings  wet  in  alcoholic  solution  of  salicylic  acid 
may  be  used  for  a  protracted  period  of  time;  if  the  swelling  does  not 
subside  under  their  use,  the  tumor  may  be  reduced  by  the  excision  of 
wedge-shaped  pieces  of  tissue. 

Certain  forms  of  cancer  also  affect  the  scrotum.  Frequent  irrita- 
tion such  as  may  be  produced  by  eczema  in  hot  countries,  or  by  chem- 
ical substances,  such  as  are  contained  in  sut,  paraffin  and  anilin  prod- 
ucts, are  responsible  for  the  development  of  these  growths. 

Chimney-sweepers'  cancer,  as  well  as  that  due  to  the  anilin  products 
or  fumes  of  tar,  begins  as  wart-like  growths  at  the  root  of  the  penis, 
and  may  remain  as  such  for  a  long  time.  It  generally  extends  super- 
ficially before  it  invades  the  deep  structures  and  involves  the  lymph- 
atics, thereby  giving  rise  to  metastatic  processes,  so  that  extirpation 
offers  a  comparatively  favorable  prospect  of  cure.  [These  growths 
are  really  epitheliomata.]  True  carcinoma  also  occurs  in  the  scrotum 
as  in  other  parts  of  the  body,  and  its  cause  here  is  as  little  understood 
as  it  is  in  other  regions. 

Treatment  consists  in  a  careful  and  thorough  removal  of  the  diseased 
tissue.  Here  as  elsewhere  the  first  principle  is  thorough  extirpation. 
It  is  essential  to  operate  in  healthy  tissue,  beyond  the  diseased  parts, 
and  this  should  be  done  though  it  necessitates  sacrifice  of  a  part  of 
the  sexual  organs.  Haemorrhage  is  usually  abundant,  and  special  care 
must  be  taken  to  control  it. 

Of  tumors  affecting  the  tunica  vaginalis,  cysts,  lipomata  and  fibro- 
mata have  been  observed;  very  rarely  enchondromata,  myomata 
and  sarcomata  have  been  found.  These  tumors  are  confined  strictly 
to  the  tunica  vaginalis,  being  distinct  from  the  testicle,  epididymis 
and  cord,  so  that  they  can  be  removed  without  injuring  these  structures. 
Lipoma  usually  affects  the  tunica  communis,  the  others  the  tunica 
propria.  If  lipomata  remain  small  they  may  not  require  treatment. 
Fibromata  are  large  and  therefore  should  be  extirpated,  and  the  genital 


TUMORS    OF    THE    TESTICLE    AND    EPIDIDYMIS.  419 

organs  thereby  preserved;  in  myxomata  and  sarcomata  it  is  necessary 
to  remove  the  testicle,  dividing  the  cord  as  high  up  as  possible. 

TUMORS  OF  THE  TESTICLE  AND  EPIDIDYMIS. 

Of  the  numerous  tumors  affecting  the  testicle  and  epididymis 
fibroma,  enchondroma,  myxoma,  and  the  rare  myoma  present  neither 
clinical  nor  histological  peculiarities.  For  this  reason  a  detailed 
description  of  them  may  be  dispensed  with.  It  may  be  stated,  how- 
ever, that  all  these  tumors,  and  likewise  those  about  to  be  mentioned, 
are  apt  to  occur  in  mixed  form. 

More  frequent  than  the  aboved  named  is  sarcoma  of  the  testis  and 
epididymis,  which,  according  to  Virchow,  occurs  during  early  childhood 
and  old  age,  although  Konig  states  that  it  is  also  met  with  in  middle 
age.  Macroscopically  there  are  two  chief  varieties  of  sarcoma,  the 
hard  and  the  soft.  As  a  rule,  the  softer  the  tumor,  the  more  malignant 
it  is.  Some  are  round-celled  and  some  spindle- celled  sarcomata.  They 
attack  the  testicle  first,  causing  considerable  enlargement  of  the 
gland,  then  after  a  short  time  they  advance  to  the  epididymis,  and 
finally  break  through  the  tunica  albuginea.  After  this  happens  they 
grow  very  rapidly,  become  adherent  to  the  skin  and  perforate  exter- 
nally, or  extend  upwards  along  the  cord  to  the  inguinal  glands,  and 
then  become  widely  disseminated,  giving  rise  to  metastases  in  remote 
organs  of  the  body,  such  as  the  brain,  the  lungs  and  the  liver. 

Kraske  thinks  that  trauma  is  the  cause  of  these  sarcomata. 

Treatment  consists  in  castration  at  the  earliest  possible  moment. 
It  is  only  when  the  tumor  is  still  confined  within  the  tunica  albuginea 
that  there  is  any  hope  of  cure;  otherwise  the  metastases  in  other  organs 
render  operation  fruitless. 

The  cystic  testicle,  cystoma  or  adenoma  testis,  which  has  been  care- 
fully studied  by  Billroth,  Virchow  and  Kocher,  is  the  direct  analogue  of 
the  cystic  ovary.  It  is  a  cysto-adenoma,  and  results  from  overgrowth 
and  constriction  of  the  seminiferous  tubules,  as  the  result  of  which 
cystic  dilatation  of  the  constricted  part  takes  place.  If  proliferation 
has  the  ascendency  the  tumor  more  closely  resembles  adenoma,  but  if 
cyst-formation  predominates  it  is  of  the  type  of  cystoma. 

As  long  as  the  tumor  remains  distinctly  adenomatous  or  cystic  it 
may  be  classified  among  benign  growths,  but  when  sarcomatous 
portions  are  found  in  it,  which  is  exceptional,  it  is  then,  of  course, 
malignant.     These   tumors   are   characterized   by   the   fact   that   the 


420  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

epididymis  and  vas  deferens  usually  remain  free.  The  tissue  of  the 
testicle  partly  covers  the  tumor  as  a  smooth  flat  coating  and  partly 
insinuates  itself  between  the  cysts  and  the  solid  portions  of  the 
growth.  These  growths  may  attain  the  size  of  a  man's  head;  they 
usually  have  a  smooth  surface,  are  soft  and  elastic  and  occasionally 
fluctuate. 

Cystoma  of  the  testicle  usually  occurs  between  the  ages  of  twenty 
and  forty,  that  is,  at  a  period  of  life  during  which  strength  and  the 
power  of  procreation  are  at  their  height.  It  grows  rapidly  and  some- 
times causes  great  pain.  For  the  purpose  of  confirming  diagnosis 
puncture  may  be  made,  although  the  results  obtained  thereby  will 
seldom  be  conclusive.  For  this  reason  incision  is  indicated.  During 
the  operation  it  can  be  decided  whether  conservative  treatment  is 
possible  or  whether  castration  is  necessary.  [If  the  tumor  proves  to  be 
a  cyst-adenoma  it  should  be  removed.  An  old  hematocele  might  be 
mistaken  for  a  cystic  testicle,  and  in  such  a  case  the  testicle  would 
naturally  be  left  undisturbed  after  the  clots  had  been  turned  out.] 

Carcinoma  of  the  testicle  is  more  common  than  sarcoma.  It  occurs 
in  two  forms,  the  hard  and  the  soft,  or  schirrus  and  alveolar.  Clinically, 
the  two  forms  may  be  differentiated  by  the  fact  that  the  medullary 
type  grows  more  rapidly  than  the  schirrus  and  is  of  a  more  symmetrical 
shape  and  softer  consistency;  the  schirrus  grows  slowly,  is  of  irregular 
form,  and  shows  well-marked  dense  nodules.  The  retroperitoneal 
lymph  glands  into  which  the  lymphatics  of  the  testicle  drain  become 
infiltrated  early  in  the  disease;  they  lie  on  each  side  of  the  vertebral 
column  on  a  level  with  the  kidneys. 

As  long  as  the  neoplasm  remains  confined  within  the  tunica  albuginea 
the  enlarged  testicle  maintains  its  ovoid  shape ;  when  it  breaks  through 
this  structure,  however,  the  testicle  assumes  an  irregular  shape,  grows 
more  rapidly,  becomes  adherent  to,  and  finally  perforates,  the  skin  of 
the  scrotum. 

The  prognosis  of  carcinoma  of  the  testicle  is  very  unfavorable, 
because  the  inguinal,  iliac  and  retroperitoneal  lymph-glands  become 
involved  early  in  the  disease,  usually  before  a  positive  diagnosis  can 
be  made. 

The  only  treatment  of  any  value  is  early  extirpation  of  the  diseased 
testicle. 

[Teratomata.  The  mixed  tumors  above  mentioned  are  probably 
all    teratomata,    that    is,    congenital    tumors    containing   embryonal 


PLATE   XVI. 


Chorio-epithelioma  of  the  Testicle.     Drawing  from  a  specimen  removed  by  Dr.  W. 
Joseph  Hearn.     (A  microscopic  section  of  this  tumor  is  shown  in  Plate  XVIT.) 


TUMORS    OF    THE    TESTICLE    AND    EPIDIDYMIS.  42 1 

elements  from  the  three  blastodermic  layers.  Dermoid  cysts  also 
belong  to  this  class. 

Various  theories  have  been  advanced  to  account  for  the  development 
of  these  growths,  but  as  they  are  of  more  interest  to  the  pathologist 
and  embryologist  than  to  the  surgeon  and  practitioner  they  will  not  be 
discussed  in  detail  here. 

The  important  thing  for  us  to  remember  is  that  these  growths  are 
much  more  dangerous  than  they  usually  have  been  considered  to  be, 
and  that  their  presence  demands  a  radical  operation. 

Wilms,  in  his  classic  paper  on  teratoma  of  the  testicle,  has  reported 
ten  cases  of  mixed  tumors,  two  of  which  proved  to  be  malignant. 
F.  R.  Sturgis,  of  New  York,  has  also  collected  from  literature  forty 
cases  of  what  he  terms  cystoid  disease  of  the  testicle,  many  of  which, 
however,  were  evidently  teratomata.  His  own  case  likewise  may  be 
rightly  classed  under  this  heading.  One-fourth  of  this  number  showed 
signs  of  malignancy,  and  in  sixteen  cases  fatal  metastases  occurred. 

In  1902  Wlasson  and  Schlagenhaufer  called  attention  to  the  presence 
in  teratomata  of  tissue  resembling  chorio-epithelium,  and  since  that 
time  other  cases  have  been  reported  by  Carey,  Steinhaus,  Pick,  Smauch, 
Scott  and  Longcope,  and  Robert  Frank.  The  accompanying  illustra- 
tions (Plates  XVI  and  XVII)  show  the  macroscopic  and  microscopic 
appearance  of  an  enormous  tumor  of  this  kind  which  was  recently 
removed  by  Dr.  Joseph  Hearn,  of  Philadelphia.  The  clinical  diagnosis 
was  carcinoma,  and  the  true  nature  of  the  growth  was  revealed  only 
upon  microscopic  examination.  Fatal  metastases  occurred  within  a  few 
months  after  the  tumor  was  removed. 

These  tumors,  like  chorio-epithelioma  of  the  uterus  and  vagina, 
are  of  the  most  malignant  type. 

That  many  growths  diagnosticated  as  carcinoma  and  sarcoma  wTere 
in  reality  teratomata  containing  chorio-epithelium,  is  attested  by  the 
recent  investigations  of  Robert  Frank,  of  New  York,  who,  by  the  way, 
has  collected  nineteen  authentic  cases,  not  including  the  one  here 
mentioned. 

There  is  a  diversity  of  opinion  in  regard  to  the  origin  of  the  chorio- 
epitheliomatous  tissue  in  these  tumors.  Thus,  Schlagenhaufer  believes 
that  they  develop  from  isolated  blastomeres  or  fertilized  polar  bodies. 
Risel  and  Pick,  who  think  they  have  observed  transitional  epithelium 
in  the  masses,  are  of  the  opinion  that  the  latter  are  formed  from  the 
epiblast.     Scott  and  Longcope  have  called  attention  to  "the  possibility 


42  2  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

of  the  chorio-epithcliomatous  elements  present  in  a  teratoma  composed 
of  all  three  germinal  layers  growing  more  rapidly  than  the  other  elements 
and  thus  causing  disappearance  of  the  latter  or  so  outgrowing  them 
that  they  are  difficult  to  detect  unless  serial  sections  be  made." 

As  has  already  been  stated,  the  important  thing  for  the  practitioner 
to  remember  is  the  possible  malignancy  of  all  growths  of  the  testicle 
the  nature  of  which  is  obscure.  I  would  advise  the  removal  of  any 
suspicious  tumor  of  the  testicle  which  does  not  yield  rapidly  to  ener- 
getic antisyphilitic  treatment.  In  doubtful  cases  mercury  and  the 
iodides  in  large  doses  are  always  to  be  tried.  If  they  fail  to  act  within 
a  short  time  recourse  should  be  had  to  operation.] 

TUBERCULOSIS    OF    THE    TESTICLE,    EPIDIDYMIS    AND 

VAS  DEFERENS. 

Tuberculosis  of  the  genital  glands  is  a  relatively  frequent  disease. 
It  may  develop  either  primarily  or  as  a  metastasis  from  a  remote 
tuberculous  focus  (as  in  the  lungs  for  example),  or  extend  from  neighbor- 
ing structures.  In  case  of  the  last  mentioned  occurrence,  the  urinary 
tract  or  the  seminal  vesicles  are  usually  the  seat  of  the  primary  lesions. 
It  also  often  happens  that  a  descending  renal  tuberculosis  with  asso- 
ciated tuberculous  cystitis  is  the  source  of  the  trouble. 

As  exciting  causes  trauma  and  gonorrhoea  are  especially  to  be 
blamed,  since  they  may  lead  to  the  development  of  tuberculosis  in 
persons  who  are  predisposed  to  this  disease. 

Although  in  certain  persons  injury  results  in  an  acute  inflamma- 
tion of  the  testicle  and  epididymis  which  soon  subsides,  and  gonorrhceal 
epididymitis  undergoes  resolution  with  the  exception  of  leaving  a 
small  infiltrate  behind,  in  other  persons  tuberculosis  will  follow 
either  of  these  conditions,  and  that,  too,  when  not  a  trace  of  it  could  be 
found  before  in  any  part  of  the  body.  In  these  cases  it  must  be  assumed 
that  tubercle  bacilli  circulating  in  the  blood  select  for  their  abode 
the  point  of  least  resistance — and  the  epididymis  is  to  be  considered 
as   such — and   there   cause   the   development   of   tuberculosis. 

The  disease  almost  always  begins  in  the  epididymis  or  vas  deferens, 
very  rarely  in  the  testicle  itself,  which  becomes  involved  later  as  the 
disease  progresses  in  the  epididymis.  This  mode  of  advancement  may 
be  considered  the  rule,  and  made  use  of  in  diagnosis.  It  is  either  in 
the  head  or  the  tail  of  the  epididymis  that  the  formation  of  tubercles 


PLATE  XVII. 


Microscopic  section  of  the  tumor  shown  in  Plate  XVI.     A  A.  Large  syncytial  cells. 


29 


TUBERCULOSIS  OF  THE  TESTICLE,  EPIDIDYMIS  AND  VAS  DEFERENS.    423 

first  takes  place;  it  is  exceedingly  uncommon  for  the  portion  between 
the  two  extremities  to  be  the  site  of  the  first  tubercles,  although  in  rare 
instances  the  entire  organ  may  be  affected  at  once. 

Fortunately  the  disease  in  the  beginning  is  usually  unilateral,  although 
it  often  comes  to  pass  that  the  other  testicle  becomes  tuberculous.  [I 
have  seen  marked  involvement  of  the  second  testicle  within  three 
months  after  removal  of  its  fellow,  and  this  in  a  case  in  which  operation 
was  performed  within  ten  days  after  the  patient's  attention  was  attracted 
to  his  condition.  No  signs  of  pulmonary  or  renal  tuberculosis  could 
be  detected  in  this  case.]  The  morbid  process  extends  along  the  vas 
deferens  if  this  structure  was  not  its  primary  seat.  Later  the  prostate, 
seminal  vesicles  and  bladder  may  become  involved,  or,  as  more  fre- 
quently happens,  the  disease  begins  in  the  seminal  vesicles  and  extends 
downwards  to  the  epididymis.  As  concerns  the  urinary  tract,  it  may 
be  stated  that  it  is  more  common  for  tuberculosis  of  the  prostate  and 
epididymis  to  invade  the  bladder  than  it  is  for  vesical  tuberculosis 
to  encroach  upon  the  epididymis. 

The  tuberculous  process  originates  in  the  walls  of  the  seminiferous 
tubules,  which  become  converted  into  tuberculous  tissue;  owing  to  dis- 
integration of  these  newly  formed  masses  caseous  foci  are  produced 
which  may  coalesce  and  form  cavities.  Later  the  testicle  itself  becomes 
the  seat  of  such  tubercles,  which  undergo  the  same  changes  as  do  all 
others,  at  first  softening  in  the  center  and  then  becoming  caseous  toward 
the  periphery.  For  a  time  the  tunica  vaginalis  remains  free,  but  sooner 
or  later  it  generally  becomes  adherent  to  the  surface  of  the  testicle. 
Miliary  tubercles  may  also  be  found  on  the  outer  surface  of  the  tunic. 
Occasionally  hydrocele  occurs.  [I  have  found  fluid  in  the  cavity  of 
the  tunica  vaginalis  in  several  cases. 

Plate  XVIII  shows  extensive  destruction  of  the  parenchyma  of  the 
testicle  by  tuberculosis.] 

In  regard  to  the  symptoms  and  course  of  the  disease,  it  may  be 
stated  that  its  onset  and  development  are,  according  to  my  experience 
at  least,  usually  painless.  Rarely  it  may  happen  that  a  rapid  eruption 
of  tubercles  may  give  rise  to  slight  pain.  The  course  is  generally  so 
slow  that  the  patient  does  not  notice  the  beginning  of  the  disease ; 
accidental  pressure  upon  the  testicle,  or  enlargement  of  the  scrotum, 
may  first  direct  his  attention  to  the  fact  that  something  is  wrong. 
Neither  fever  nor  other  constitutional  disturbance  is  present. 

It  is  not  only  enfeebled  or  phthisical  subjects  who  are  attacked  by 


424  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

this  malady,  but  also  strong  young  persons  in  whom  no  one  would  ever 
suspect  tuberculosis.  For  this  reason  the  disease  may  be  purely 
local,  and  may,  moreover,  exist  for  many  years  without  progressing  or 
giving  rise  to  metastases;  this  is  a  circumstance  which  is  of  great 
importance  in  regard  to  treatment.  This  does  not  mean,  however, 
that  in  other  cases  extension  of  the  morbid  process  does  not  take  place 
nor  metastases  occur;  as  a  rule,  though,  this  is  not  the  case. 

In  regard  to  the  objective  symptoms,  it  may  be  stated  that  in  the 
beginning  one  or  more  tubercles  can  be  palpated  in  the  head  or  tail  of 
the  epididymis.  If  the  vas  deferens  be  followed  up  toward  the  inguinal 
canal  spindle-shaped  swellings,  representing  tubercles,  may  perhaps 
be  felt,  although  in  some  cases  the  vas  will  be  entirely  free. 

The  nodules,  which  gradually  become  adherent  to  the  surrounding 
tissues  may,  as  has  already  been  stated,  remain  unchanged  for  years, 
but  they  may  also  soften  slowly  and  finally  break  through  the  skin, 
which  has  gradually  become  thinner  and  thinner.  In  such  cases 
fistulas  develop  which  show  little  inclination  to  heal,  but,  on  the  con- 
trary, dissect  their  way  more  and  more  through  the  tissues,  forming 
indurated  tracts  from  their  external  orifice  to  the  original  site  of  the 
tuberculous  foci  from  which  they  sprung.  Very  rarely  these  fistulas 
close  spontaneously,  leaving  a  cicatricial  cord  behind;  as  a  rule,  how- 
ever, tuberculous  granulations  grow  out  from  them  and  they  extend 
further  and  further  into  the  neighboring  parts. 

The  general  health,  as  has  already  been  stated,  is  often  not  affected, 
but  it  must  not  be  forgotten  that  in  many  cases  the  lesion  in  the  testicle 
is  only  one  of  several  tuberculous  foci  which  are  present  in  the  body. 
In  such  cases,  of  course,  the  severity  of  the  constitutional  manifesta- 
tions will  depend  upon  the  vital  importance  of  the  organs  affected  and 
the  extent  of  the  morbid  process  in  which  they  are  involved. 

Differential  diagnosis  between  tuberculosis  and  other  diseases  of  the 
testicle  depends  upon  the  slow  course  of  the  former;  the  presence 
only  in  slight  degree,  or  perhaps  the  entire  absence,  of  pain;  the  rough 
tuberculated  surface  of  the  gland;  the  primary  involvement  of  the 
epididymis;  the  adherence  of  the  testicle  to  the  skin;  the  development 
of  persistent  fistulas,  and  finally  the  presence  of  tuberculous  foci  in 
other  parts  of  the  body.  [Pain  and  swelling  of  the  scrotum  may  be 
the  first  thing  to  attract  the  patient's  attention.  So  insidious  is  the 
evolution  of  the  disease  that  it  may  attain  an  advanced  stage  before 
giving  rise  to  any  symptoms,  and  then,  when  the  testicle  becomes 


PLATE  XVIII. 


Advanced  Tuberculosis  of  the  Testicle.     (Drawing  from  a  specimen  in  the  Phipps 
Institute.) 


TUBERCULOSIS  OF  THE  TESTICLE,  EPIDIDYMIS  AND  VAS  DEFERENS.    425 

adherent  to  the  skin,  soreness  and  pain  will  develop  as  the  initial 
manifestations  of  the  long-existing  disorder. 

In  a  patient  whom  I  recently  operated  on  acute  hydrocele,  together 
with  acute,  intensely  painful  inflammatory  swelling  of  the  superficial 
coverings  of  the  testicle,  were  the  first  signals  of  trouble.  Examina- 
tion of  the  diseased  gland,  however,  showed  an  advanced  chronic 
tuberculosis;  there  were  both  caseated  and  calcified  areas  in  the  tes- 
ticle and  epididymis,  and  also  an  eruption  of  miliary  tubercles  on 
the  tunica  vaginalis.  Yet,  despite  the  long  duration  of  the  morbid 
process,  no  disturbance  was  produced  until  the  parts  became  acutely 
inflamed  and  distended  by  the  effusion  of  fluid.  Therefore,  it  is  to 
be  remembered  that,  in  exceptional  cases,  the  first  symptom  may  be 
pain,  the  first  sign,  acute  inflammation.] 

The  prognosis  differs  greatly  according  to  whether  the  epididymis 
is  the  only  site  of  disease,  whether  there  are  foci  present  in  other  parts 
of  the  genito-urinary  tract,  or  whether  the  lesion  represents  a  metastasis 
from  tuberculous  areas  in  remote  parts  of  the  body.  The  prognosis  is 
by  no  means  unfavorable.  If  the  disease  is  unilateral  it  may  heal 
spontaneously  or  be  entirely  overcome  by  operation.  Associated 
pulmonary  or  renal  tuberculosis  naturally  render  prognosis  much  less 
favorable. 

As  regards  treatment  it  may  be  stated  that  the  measures  to  be  adopted 
in  dealing  with  tuberculosis  of  the  organs  now  under  discussion  depend 
upon  a  variety  of  circumstances.  When  there  is  an  associated  pulmon- 
ary or  renal  tuberculosis  it  is  evident  that  treatment  will  be  symptom- 
atic and  palliative.  In  cases  in  which  the  general  health  is  good, 
however,  it  must  not  be  forgotten  that  tuberculosis  of  the  testicle  is 
often  merely  a  local  disease,  and  that  after  it  is  overcome  the  organism 
may  remain  free  from  further  tuberculous  infection.  So,  too,  if  unilat- 
eral nephrotuberculosis  be  coexistent  with  tuberculosis  of  the  testicle 
on  the  corresponding  side,  it  may  be  possible  to  effect  a  complete  cure 
by  removing  both  the  diseased  organs.  In  cases  where  the  disease  is 
unilateral  the  chances  of  complete  recovery  are  increased  if  no  delay 
is  tolerated  in  effecting  the  removal  of  the  tuberculous  organs,  namely, 
the  testicle,  epididymis  and  greater  part  of  the  vas  deferens.  When 
both  testicles  are  diseased  the  question  becomes  more  difficult,  for 
double  castration  is  often  followed  by  severe  psychic  disturbances. 
In  these  cases  I  have  decided  upon  castration  only  when  the  disease 
was  making  rapid  progress. 


426 


TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 


In  other  cases  it  seemed  right  to  me  to  follow  a  conservative  plan, 
that  is,  to  order  roborant  general  treatment,  and  if  fistulas  were  present 
to  lay  them  open,  curette  them,  cauterize  individual  foci,  and  treat  the 
wound  with  iodoform.  This  plan  is  the  more  justifiable  as  cases 
no  doubt  do  occur  in  which  tuberculosis  of  the  testicle  and  epididymis 
heal  spontaneously.  The  cure  may  follow  sloughing  of  the  affected 
parts,  calcification,  or  fibrous  change. 

Resection  of  the  epididymis  with  preservation  of  the  testicle,  as 
proposed  by  Bardeleben,  does  not  seem  rational,  because  there  is  no 
means  by  which  it  can  be  determined  whether  tuberculous  foci  which 
cannot  be  palpated  and  recognized  are  not  present  in  the  parenchyma 
of  the  testicle. 

[THE  OPERATION  OF  CASTRATION.] 

This  operation  varies  according  to  the  lesion  for  which  it  is  per- 
formed. For  the  removal  of  tuberculous,  gangrenous,  or  injured  testicles 
an  incision  is  begun  at  the  external  abdominal  ring  and  carried  down- 
wards through  the  skin  and  subcutaneous 
tissues  of  the  scrotum  for  a  distance  suffi- 
cient to  make  an  opening  which  will 
readily  permit  the  passage  of  the  testicle. 
(Fig.  202.)  The  length  of  this  incision 
will  vary  in  different  cases. 

When  fistulas  are  present  the  incision 
should  be  so  shaped  as  to  include  them 
in  a  portion  of  the  skin  which  is  to  be 
removed  with  the  testicle. 

All  bleeding  points  are  caught  with 
haemostatic  forceps,  the  testicle  freed  by 
blunt  dissection,  the  cord  likewise  liber- 
ated, and  the  whole  mass  drawn  out  of 
the  scrotum.  The  cord  is  now  ligated 
in  two  portions  with  strong  chromic 
catgut  and  divided  below  the  ligature. 
(Fig.  203.)  I  use  an  aneurysm  needle  for  separating  the  constituent 
structures  of  the  cord,  passing  it  through,  then  threading  it  and  draw- 
ing it  back.  When  operating  for  tuberculosis  the  cord  should  be 
ligated  as  high  up  as  possible.  Some  surgeons  crush  the  cord  with 
strong  forceps  or  the  angiotribe  before  ligating  it.     A  strong  ligature; 


,  Fig.   202 
operation  of  castration 


The  incision  in  the 


(Veau.) 


THE    OPERATION    OE    CASTRATION. 


427 


firmly  tied,  has  never  failed  me,  so  I  do  not  practise  the  latter  pro- 
cedure. 

Before  closing  the  wound  bleeding  must  be  carefully  arrested. 
The  cavity  within  the  scrotum  should  be  irrigated  with  hot  normal 
salt-solution,  sponged  dry  with  sterilized  gauze,  and  any  bleeding 
points  caught  with  haemostatic  forceps  and  twisted  or  tied.  It  is 
essential  to  prevent  the  formation  of  a  haematoma.  The  cavity  should 
be  drained  for  twenty-four 
hours  with  a  small  tube,  or  a 
few  strands  of  silkworm  gut 
inserted  through  the  lower 
angle  of  the  incision. 

In  operating  for  malignant 
tumors  of  the  testicle,  partic- 
ularly carcinoma,  a  more  ex- 
tensive procedure  is  absolutely 
necessary. 

It  will  be  remembered  that 
the  lymphatic  vessels  of  the 
testicle  accompany  the  sper- 
matic cord  as  far  as  the  lum- 
bar region  and  then  diverge  *>  203.-The  cord  has  been  ligated  in  two 
o  o       portions  and  divided  below  the  ligature.     1  he 

to    pursue    their    COUrse  to  the     stump  is  seen  at  the  upper  angle  of  the  wound. 
1        1      •    ,         i-i       (Veau.) 

juxta-aortic  glands,  into  which 

they  empty.  Although  it  is  impossible  to  reach  them  at  their  termi- 
nation, every  portion  of  them  which  is  accessible  should  be  removed. 
This  is  the  only  rational  surgical  procedure. 

Following  the  method  of  Cumston  and  Rolfe,  an  incision  is  made 
parallel  to,  and  about  one-half  or  three-quarters  of  an  inch  above, 
Poupart's  ligament,  the  inguinal  canal  laid  open,  the  cord  freed  and 
lifted  out.  The  iliac  fossa  is  then  entered  by  an  opening  made  through 
the  posterior  wall  of  the  canal.  The  vas  is  followed  downward  into 
the  pelvis  as  far  as  possible,  tied,  cut,  and  the  stump  touched  with  pure 
carbolic  acid.  The  spermatic  vessels  are  then  traced  upward  as  far 
as  possible,  ligated  in  two  places  and  divided  between  the  ligatures. 
The  cord  is  separated  from  its  coverings  from  above  downward  to  a 
point  below  the  external  ring.  The  testicle,  if  not  too  much  enlarged, 
may  be  pressed  upward  and  forced  out  through  the  opening  above 
Poupart's  ligament,  where  it  is  removed  together  with  the  cord. 


428  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

If  the  growth  be  very  large  it  will  be  necessary  to  make  a  longitu- 
dinal incision  down  the  scrotum  in  order  to  remove  it. 

Whenever  a  malignant  tumor  is  adherent  to  the  scrotum  the  skin 
must  be  freely  excised,  and  the  inguinal  glands  also  dissected  out,  as 
the  lymphatics  of  the  scrotum  empty  into  them. 

SYPHILIS  OF  THE  TESTICLE  AND  EPIDIDYMIS. 

Syphilis  occurs  in  the  testicle  and  epididymis  in  two  different  forms: 
gummata,  and  diffuse  overgrowth  of  the  connective  tissue  in  which 
the  seminal  tubules  are  destroyed  and  extensive  indurations  formed. 
Both  forms  may  be  present  simultaneously. 

Concerning  the  development  of  this  affection  I  shall  ignore  the 
rare  instances  in  which  the  testicle  and  epididymis  are  involved  at  the 
outbreak  of  lues  and  consider  only  those  in  which  it  occurs  as  a 
late  manifestation  of  the  infection.  As  is  often  the  case  with  localized 
syphilitic  lesions,  injury  or  inflammation,  as  for  example,  a  gonorrhceal 
epididymitis,  may  act  as  exciting  causes.  Although  orchitis  and 
epididymitis  are  among  the  most  frequent  localized  syphilitic  lesions, 
it  is  well-known  that  the  syphilitic  virus  may  be  present  in  the  semen 
of  persons  in  whose  genital  organs  no  signs  of  lues  can  be  found. 

The  clinical  picture  of  syphilitic  orchitis  is  not  very  distinctly  delin- 
eated. The  disease  develops  insidiously,  the  testicle  gradually  becom- 
ing larger,  but  yet  not  attaining  an  excessive  size.  An  important 
point  of  differential  diagnosis  is  that,  in  contradistinction  to  tubercu- 
losis, in  syphilis  the  testicle  is  almost  always  affected  before  the  epididy- 
mis, and  that  the  vas  deferens,  as  a  rule,  remains  uninvolved.  The 
swelling  may  be  diffuse,  or  hard  nodules  of  varying  size  may  be 
detected;  the  former  condition  is  the  more  common.  The  testicle  is 
firm  and  elastic,  and  apparently  fluctuates,  so  that  the  condition  is 
not  uncommonly  confounded  with  hydrocele.  In  isolated  cases  the 
diffuse  swelling  may  gradually  subside  and  a  small  indurated  testicle 
remain.  When,  as  more  frequently  happens,  owing  to  mistaken 
diagnosis,  antisyphilitic  treatment  is  not  given,  the  nodules  soften  and 
perforate  through  the  skin  of  the  scrotum,  thus  forming  ulcers.  The 
testicle  may  prolapse,  but  the  opening  is  generally  diminished  in  size 
by  the  proliferation  of  granulation  tissue  which  forms  the  so-called 
fungus  syphiliticus.  The  disease  is  painless;  sensitiveness  is  neither 
present  nor  can  it  be  elicited  by  pressure. 


SYPHILIS    OF    THE    TESTICLE    AND    EPIDIDYMIS.  429 

Other  manifestations  of  syphilis  may  be  found,  their  nature  depend- 
ing upon  the  stage  of  the  disease  during  which  they  occur.  As  little 
as  the  disease  annoys  the  patient  or  affects  the  general  health  its  results 
may  nevertheless  be  most  serious.  When  bilateral  it  may  produce 
sterility.  This  does  not  usually  happen,  however,  unless  the  diagnosis 
has  been  made  very  late  and  treatment  delayed  until  destruction  of 
the  glands  has  become  most  extensive.  As  a  rule,  some  functionally 
active  tissue  will  remain. 

In  regard  to  diagnosis,  which  cannot  always  be  easily  made,  the 
following  points  are  to  be  observed:  the  history  of  the  case;  other  signs 
of  recent  or  tardy  syphilis;  gradual  development  of  the  swelling  without 
pain;  involvement  of  the  testicle  first;  non-involvement  of  the  vas 
deferens  in  contradistinction  to  its  participation  in  tuberculosis; 
freedom  of  the  lymph-glands  in  contradistinction  to  their  implication 
in  malignant  growths.  In  cases  in  which  diagnosis  remains  obscure 
despite  the  consideration  of  these  data,  the  therapeutic  test  may  be 
applied.  A  course  of  mercury  followed  by  large  doses  of  potassium 
iodide,  will,  if  benefit  follows  its  employment,  enable  one  to  conclude 
that  the  tumor  in  question  was  of  syphilitic  origin. 

Prognosis  as  to  life  is  good ;  prognosis  as  to  recovery  is  also  favorable 
provided  that  treatment  be  not  too  long  delayed.  It  is  only  when  the 
lesion  is  congenital  that  complete  destruction  of  the  testicle  is  wont  to 
take  place. 

Treatment  consists  primarily  in  the  energetic  employment  of  mer- 
cury or  potassium  iodide,  or  of  both.  In  recent  cases  mercury  is  the 
drug  of  preference,  in  the  older  ones  potassium  iodide.  Mercurial 
plaster  should  also  be  applied  to  the  testicle.  As  in  constitutional 
syphilis  these  measures  may  be  supplemented  by  bathing  cures. 

If  perforation  has  taken  place  the  resulting  ulcer  should  be  treated 
in  accordance  with  the  established  principles  of  surgery,  and  an  energetic 
antisyphilitic  treatment  instituted.  Local  applications  of  sublimate 
solution  1 :  3000,  the  dressing  being  renewed  every  two  hours,  act 
excellently.  Under  this  treatment  the  necrotic  portion  of  the  testicle 
will  usually  slough  away,  the  wound  become  healthy  and  healing  take 
place,  so  that  the  greater  part  of  the  gland  will  be  preserved.  It  is 
only  in  exceptional  cases,  where  extensive  destruction  of  the  paren- 
chyma of  the  testicle  is  rapidly  taking  place  despite  energetic  treat- 
ment, that  the  surgeon  will  be  compelled  to  perform  castration. 

It  is  not  unusual  to  see  recurrences  of  the  disease  after  healing  has 


430  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

once  taken  place;  they  are  to  be  treated  in  exactly  the  same  way  as 
was  the  previous  manifestation  of  the  disease. 

ORCHITIS. 

Acute  inflammation  of  the  testicle  is  exceedingly  less  common  than 
inflammation  of  the  epididymis.  Both  are  produced  by  the  same 
causes;  sometimes  it  is  an  injury,  sometimes  extension  of  an  infective 
process  from  neighboring  parts,  as  for  instance  gonorrhoea,  prostatic 
disease,  or  vesical  catarrh,  which  gives  rise  to  the  inflammation. 
Orchitis  of  urethral  origin  may  be  accompanied  by  inflammation  of 
the  epididymis  and  vas  deferens,  but  these  structures  may  also  escape, 
the  inflammatory  process  being  confined  entirely  to  the  testicle. 

Rarely  both  forms  may  be  of  metastatic  origin.  In  mumps  acute 
orchitis  may  occur,  and  it  is  noteworthy  that  the  complication  may 
ensue  after  the  inflammation  of  the  parotid  has  sub- 
sided, and  that  the  disease  may  affect  the  testicle  first. 
Kocher  found  the  typhoid  bacillus  in  the  testicle  in  a 
case  of  orchitis  which  occurred  as  a  complication  of 
typhoid  fever.  Finally  there  remain  to  be  mentioned 
orchitis  of  rheumatic  and  malarial  origin,  the  latter  of 
which  reacts  to  quinine. 

The  symptoms  consist  of  pain,  tenderness  upon 
chitis2°Testide  Pressure>  enlargement  of  the  testicle,  and  constitutional 
swollen,  epididy-  disturbance. 

mis  lengthened.  .  .  .  .  ,         .       . 

ram  may  be  severe.  It  is  characterized  by  the  fact 
that  it  persists  while  the  patient  remains  in  the  dorsal  position,  and 
that  it  either  may  be  confined  to  the  testicle  alone  or  radiate  to  the 
loins  and  back.  These  pains  in  the  back  are  to  be  considered  either 
as  reflex  neuralgia  or  as  peripheral  neuritis. 

Upon  palpation  the  testicle  is  found  to  be  swollen  and  very  sensitive 
to  pressure.  The  epididymis  lies  behind  the  testicle  and  is  lengthened 
by  the  swelling  of  the  former,  so  that  it  feels  like  a  thick  cylindrical 
tumor.  (Fig  204.)  The  testicle  may  swell  very  rapidly,  sometimes 
becoming  as  large  as  a  goose's  egg  within  twenty-four  hours. 

,The  general  health  is  considerably  disturbed;  fever  is  present  and 
the  evening  temperature  may  rise  as  high  as  40°C.  [1040  F.].  The 
metastatic  forms  are  the  mildest.  [In  Sumatra,  Martin  observed  an 
intense  fulminating  inflammation  of  the  testicle  occurring  as  a  com- 
plication of  malaria.]    The  majority  of  cases  due  to    traumatism  also 


ORCHITIS.  43I 

pursue  a  favorable  course.  Those  due  to  urethral  disease  are  of 
longer  duration,  owing,  no  doubt,  to  the  fact  that  the  urethral  trouble 
often  persists. 

Orchitis  is  to  be  differentiated  from  epididymitis  and  hydrocele. 
Palpation  furnishes  a  sure  means  of  distinguishing  it  from  the  former, 
and,  as  a  rule,  will  also  serve  to  separate  it  from  hydrocele.  If  doubt 
exists,  it  should  be  remembered  that  hydrocele  is  usually  transparent, 
that  the  epididymis  retains  its  normal  form  in  hydrocele,  but  is  length- 
ened in  orchitis.  Fluctuation  is  a  sign  of  little  worth,  because  in  orchi- 
tis the  swollen  testicle  may  apparently  fluctuate. 

The  intense  swelling  is  due  to  serous  infiltration  and  intense  hyper- 
emia of  the  substance  of  the  testicle.  If  the  process  advances  further, 
the  testicular  tissue  is  seen  to  be  of  a  yellow  color  when  the  gland  is 
sectioned.  Along  the  septa  and  albuginea,  and  in  the  substance  of 
the  gland  as  well,  small  circumscribed  areas  of  suppuration  are 
found  which  later  coalesce.  The  albuginea  is  thickened,  the  septa 
are  broadened.  Under  the  microscope  the  connective-tissue  stroma 
is  seen  to  be  infiltrated  with  small  cells.  Wall  and  seminiferous 
tubule  and  interstitial  connective  tissue  are  all  infiltrated  with  leuco- 
cytes. 

In  regard  to  the  course  and  termination  of  the  disease,  it  may  be 
stated  that,  as  a  rule,  it  lasts  from  two  to  three  weeks. 

After  the  swelling  has  reached  its  height  and  the  pain  consequently 
attained  its  maximum  intensity,  the  fever  begins  to  subside  and  the 
temperature  soon  reaches  its  normal  level.  The  further  course  of  the 
disease  is  unattended  by  material  disturbance  of  the  organism.  In 
the  majority  of  cases  complete  restitutio  ad  integrum  results;  nodular 
infiltrates  do  not  remain  behind  as  in  epididymitis. 

A  somewhat  less  favorable  termination  is  in  atrophy  of  the  testicle, 
which  is  caused  by  the  excessive  overgrowth  of  interstitial  connective 
tissue.  The  most  unfavorable  ending  of  all  is  suppuration,  which 
may  either  extend  toward  the  periphery  and  rupture  externally,  or 
lead  to  gangrene  before  rupture  occurs.  The  greatest  danger,  how- 
ever, is  extension  of  the  suppurative  process  to  the  spermatic  cord,  with 
resulting  peritonitis  and  pyaemia.  Fortunately  this  occurrence  is 
exceedingly  rare. 

Treatment  consists  in  absolute  rest,  elevation  of  the  testicle,  applica- 
tions of  an  ice-cold  2  per  cent  solution  of  acetate  of  aluminum,  together 
with  the  internal  use  of  antipyrin  or  salicylic  acid. 


432  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

This  antiphlogistic  therapy  will  suffice  in  the  vast  majority  of  cases. 
It  may  be  necessary,  however,  to  employ  narcotics  if  the  pain  is  very 
severe. 

Although  incision  of  the  inflamed  testicle  causes  relaxation  of  the 
distended  tissues,  and  thereby  lessens  pain,  it  should  not  be  resorted 
to  for  the  reason  that  cure  almost  always  follows  without  its  employ- 
ment, and,  furthermore,  because  there  is  danger  of  prolapse  and  con- 
sequent gangrene  occurring. 

It  is  quite  different  when  there  is  reason  to  believe  that  suppuration 
is  present  and  that  resorption  will  not  take  place.  When  high  fever, 
chills,  pain,  and  swelling  persist  beyond  the  usual  time,  and  fluctuation 
makes  it  plain  that  pus  is  present,  then  no  delay  should  be  entertained 
in  making  a  free  incision.  The  danger  of  prolapse  of  the  seminiferous 
tubules  and  consequent  gangrene  is  the  only  one  to  be  feared,  but  it  is 
of  such  moment  that  incision  should  be  resorted  to  only  when  marked 
indications  exist.  Small  non-confluent  foci  of  suppuration  may  be 
present  and  give  rise  to  the  severe  symptoms  above  mentioned.  When 
this  is  the  case  incision  will  afford  relief  by  lessening  tension,  but  it 
should  not  be  employed  for  the  reason  that  the  suppurating  foci  may 
undergo  resorption.  Therefore,  as  a  prerequisite  to  operation,  pus 
should  be  obtained  by  puncture,  unless  the  symptoms  are  so  violent 
as  to  demand  surgical  intervention  even  though  pus  cannot  thus  be 
obtained  nor  fluctuation  detected. 

Chronic  orchitis  is  a  very  rare  disease,  for  the  two  affections  in  which 
chronic  inflammation  of  the  testicular  substance  occurs,  namely, 
tuberculosis  and  syphilis,  are  considered  by  themselves  as  maladies 
due  to  specific  causes.  The  term  chronic  orchitis  is  therefore  reserved 
for  a  very  few  cases  in  which  acute  orchitis  terminates  in  a  manner 
different  than  any  of  those  just  described. 

Instead  of  complete  resolution,  atrophy,  or  suppuration,  chronic 
inflammation  of  the  parenchyma  of  the  testicle  may  result.  Such 
an  occurrence  is  so  rare,  however,  that  I  am  inclined  to  believe  it 
represents  exacerbations  of  latent  inflammation  which  has  remained 
after  the  subsidence  of  an  acute  orchitis. 

Treatment  consists  in  the  long- continued  application  of  tincture 
of  iodine,  or  inunctions  of  iodine  vasogen  or  compound  iodine  ointment, 
together  with  the  use  of  Priessnitz's  compresses  and  the  wearing  of  a 
suspensory  bandage. 


EPIDIDYMITIS.  433 

EPIDIDYMITIS. 

Inflammation  of  the  epididymis  is  one  of  the  most  frequent  affections 
of  the  genital  glands.  Although  it  does  not  endanger  life  its  results 
may  be  of  far-reaching  consequence  to  the  person  who  is  affected. 
The  disease  is  characterized  by  acute  swelling  of  the  epididymis. 
Chronic  inflammation  is  always  the  result  of  a  previous  acute  process. 

As  concerns  the  causes  of  the  disease  it  may  be  stated  that  injuries, 
such  as  kicks,  blows,  or  bruises  are  occasionally,  though  rarely,  respon- 
sible for  its  development.  It  may  also  occur  as  a  metastatic  process 
in  the  course  of  infectious  diseases,  such  as  variola  and  pyaemia,  for 
instance. 

These  are  of  minor  importance,  however,  in  comparison  with  its 
most  frequent  cause,  namely,  urethral  infection,  be  it  due  to  gonor- 
rhoea, stricture,  catheterism  or  litholapaxy.  When  caused  by  any  of 
these  conditions  it  is  evident  that  the  process  is  infective.  In  one  case 
it  may  be  the  gonococci  which  give  rise  to  the  infection,  in  another 
the  microorganisms  which  reach  the  urethra  as  the  result  of  catheterism, 
or  others  which  normally  inhabit  the  urethra,  but  become  virulent 
owing  to  the  disturbed  conditions  produced  by  the  mechanical  inter- 
ference incident  to  catheterization.  It  may  happen  that  the  suppura- 
tive inflammatory  process  extends  to  the  epididymis  by  way  of  the 
ejaculatory  ducts  and  vas  deferens,  and  that  it  also  involves  these 
structures;  it  may,  however,  leave  the  vas  unscathed  and  establish 
itself  in  the  epididymis;  and,  finally,  the  agents  of  infection  may  be 
carried  to  the  epididymis  by  the  lymphatics. 

Epididymitis  is  such  a  common  complication  of  gonorrhoea  that 
about  20  per  cent  of  all  men  affected  with  the  latter  disease  are  attacked 
by  it.  Although  it  may  occur  in  any  stage  of  the  disease,  it  is  uncom- 
mon before  the  second  week;  from  this  period,  however,  there  is  no 
limitation  to  its  incidence.  I  have  seen  cases  of  chronic  urethritis 
which  had  existed  for  years,  and  in  which  no  gonococci  had  been 
demonstrable  for  years,  become  exacerbated  and  suddenly  give  rise  to 
an  epididymitis.  Strictly  speaking  it  is  not  the  gonococcus  which 
leads  to  the  development  of  the  complication  in  this  class  of  cases, 
but  a  post-gonorrhceal  urethritis. 

Symptoms  and  Course.  The  onset  of  the  disease  is  announced 
by  slight  pain,  or  a  dragging  sensation  extending  from  the  region  of 
the  testicle  to  the  groin.  This  pain  gradually  becomes  more  intense 
and  extends  to  the  region  of  the  loins  and  pelvis.     Very  soon  it  becomes 


434  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

exceedingly  severe  in  the  testicle,  so  that  the  patient  can  scarcely  move 
without  experiencing  the  most  intense  agony;  he  seeks  instinctively 
to  support  the  scrotum. 

In  view  of  the  extreme  painfulness  of  the  testicle  and  epididymis  it 
is  not  surprising  that  the  general  health  becomes  considerably  affected. 
The  patient  is  feverish,  although  the  temperature  may  not  be  high, 
feels  weak,  and  often  experiences  a  sense  of  fainting;  indeed,  it  is 
commonly  stated  that  diseases  of  the  testicle  predispose  to  attacks  of 

syncope.  The  health  is  also  disturbed  in 
other  ways,  anorexia  being  present  and  the 
patient  looking  pale  and  generally  miserable. 
Upon  palpation  it  is  at  once  noticed  that 
the  epididymis  is  considerably  enlarged. 
The  testicle  appears  to  be  imbedded  in  the 
epididymis,  whereas  in  health  the  epididy- 

Fig.^-EpididymMsT  The    mis  HeS  UP0n  the  testicle  (F1§-  205)-      At  first 

testicle  is  imbedded  in  the  epi-  either  the  head  or  tail  may  be  affected,  but 

didymis.  .  . 

m  a  short  time,  generally  in  the  course  of  a 
few  days,  the  entire  organ  becomes  very  much  swollen,  so  that  the 
testicle  forms  the  smallest  part  of  the  scrotum.  The  skin  over  the 
swelling  is  usually  somewhat  cedematous  and  may  also  be  reddened. 

Pressure  upon  the  inflamed  epididymis,  or  even  attempt  to  palpate 
it,  gives  rise  to  violent  pain,  which  may  cause  the  patient  to  swoon. 
For  this  reason  examination  should  be  made  with  the  patient  in  the 
horizontal  position.  Palpation  will  also  disclose  the  fact  that  the  epi- 
didymis is  much  harder  than  normal;  it  feels  hard,  uneven  and  rough. 

If  the  scrotum  be  lifted  up,  the  patient  experiences  a  sense  of  relief; 
the  severe  tugging  pain  extending  well  up  toward  the  back  is  usually 
considerably  diminished.  This  pain  is  probably  produced  by  the 
increased  weight  of  the  inflamed  epididymis.  The  connective-tissue 
bands  between  the  seminiferous  tubules,  the  connective  tissue  of  the 
tunica  albuginea,  and  the  fasciculus  of  fibers  which  fasten  the  vas 
deferens  to  the  epididymis  are  all  affected  with  serous  infiltration,  and  it 
is  owing  to  this  condition  that  the  size  and  weight  of  the  organ  become 
increased,  with  the  result  that  painful  traction  is  exerted  upon  the 
spermatic  cord,  which  is  also  usually  inflamed. 

In  the  cord,  muscle,  connective  tissue,  and  especially  the  vessels, 
are  all  inflamed  and  swollen,  so  that  it  is  as  thick  as  one's  finger,  and 
can  easily  be  followed  up  to  the  external  abdominal  ring. 


EPIDIDYMITIS.  435 

Owing  to  the  narrowness  of  the  ring  pressure  is  exerted  upon  the 
swollen  plexus  of  the  cord,  and  this,  in  conjunction  with  the  traction, 
gives  rise  to  peritoneal  irritation  and  causes  an  inclination  to  vomit. 

The  pain  in  the  loins,  as  has  already  been  stated,  may  be  explained 
by  assuming  that  it  is  caused  by  traction  upon  the  cord.  It  seems  not 
improbable,  however,  that  von  Leyden  is  right  in  assuming  it  to  be 
due  to  peripheral  inflammation  which  extends  along  the  nerves  to  the 
spermatic  and  renal  plexuses.  This  view  is  corroborated  by  the 
circumstance,  that  in  many  cases  the  lumbar  pain  is  not  relieved  by 
elevation  of  the  scrotum  and  the  consequent  reduction  of  traction  upon 
the  cord,  although  the  pain  in  the  epididymis  ceases. 

The  duration  of  the  disease  may  be  stated  to  be  from  ten  to  twelve 
days.  At  about  the  tenth  day  it  is  at  its  height,  pain  and  swelling  being 
then  most  intense;  a  gradual  retrogression  of  the  inflammation  then 
begins,  the  thickening  and  induration  of  the  epididymis  subsides, 
so  that  at  the  end  of  two  weeks  more  it  has  assumed  its  normal  shape, 
with  the  exception  of  presenting  small  nodules  which  represent  the 
remains  of  the  previous  inflammation.  As  resolution  takes  place 
pain  and  fever  disappear,  and  by  the  third  week,  as  a  rule,  the  general 
health  ceases  to  be  disturbed. 

This,  the  most  frequent  termination,  is  seldom  reached  without 
the  incurrence  of  structural  changes  which  may  be  most  deleterious  to 
the  patient.  In  the  vast  majority  of  cases  the  thickening  of  the  epidid- 
ymis which  remains  is  sufficient  to  lessen  or  even  occlude  the  lumen 
of  the  vas  deferens,  so  that  the  spermatozoa  cannot  pass  through  it, 
or  if  they  do  succeed  in  getting  through,  they  have  their  vitality  much 
impaired.  If  the  affection  has  been  bilateral  complete  sterility  will 
usually  result.  I  can  state  that  the  majority  of  childless  marriages 
in  which  the  husband  is  at  fault  are  dependent  upon  a  double 
epididymitis. 

The  nodular  indurations  which  remain  may  also  become  acutely  in- 
flamed and  thus  give  rise  to  relapses.  Almost  never  is  complete  restitu- 
tio ad  integrum  obtained  so  that  the  disease  disappears  without  leaving 
any  nodules  behind. 

Among  other  complications  acute  hydrocele  and  involvement  of  the 
testicle  may  be  mentioned:  The  former  is  not  very  rare;  the  latter, 
fortunately,  is  less  frequently  met  with.  The  serous  exudation  into 
the  cavity  of  the  tunica  vaginalis  usually  persists  after  the  epididymitis 
subsides;  as  a  rule,  it  does  not  undergo  resorption.  The  inflammation 
3° 


436  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

of  the  testicle,  however,  subsides  simultaneously  with  that  of  the 
epididymis. 

A  more  important  matter  is,  that  in  feeble  persons  and  those  having 
hereditary  predisposition,  tuberculosis  maybe  superimposed  upon  the 
original  simple  epididymitis.  Therefore  special  precautions  must 
be  taken  when  such  persons  are  affected. 

In  regard  to  the  pathological  anatomy,  we  find,  according  to  Malas- 
sez  and  Terillon,  that  during  the  height  of  the  process,  the  epithelium 
of  the  seminiferous  tubules  is  swollen  and  deprived  of  its  cilia,  and  that 
their  walls  are  cedematous  and  infiltrated  with  small  cells.  As  the 
morbid  process  advances  swelling  and  small-cell  infiltration  of  the 
connective  tissue  which  surrounds  and  fastens  the  tubules  together 
occurs,  and  the  tubules  themselves  are  filled  with  greenish  yellow  fluid 
consisting  of  an  intermixture  of  pus  and  semen. 

The  nodules  remaining  after  epididymitis  consist  of  hard,  cicatricial, 
contracting  masses  of  connective-tissue  infiltrate  which  surround  the 
seminiferous  tubules. 

Treatment.  The  treatment  of  epididymitis  is  satisfactory.  The 
aim  of  treatment  should  be  to  secure  complete  cure  if  possible,  or  at 
least  obtain  entire  resolution  except  for  the  nodular  infiltrate  pre- 
viously mentioned,  and,  above  all  things,  to  prevent  termination  in 
suppuration  or  tuberculosis. 

Not  enough  attention  has  been  paid  to  the  supervention  of  tubercu- 
losis in  this  disease ;  it  is  a  matter,  however,  which  requires  the  greatest 
precautions.  In  view  of  its  likelihood  all  methods  which  interfere 
with  the  nutrition  of  the  testicle  and  epididymis  should  be  prohibited. 
For  this  reason  I  have  completely  rejected  the  Fricke  dressing,  which 
was  formerly  so  much  in  vogue. 

A  patient  with  acute  epididymitis  should  be  put  to  bed,  especially 
as  he  usually  has  slight  elevation  of  temperature.  The  testicle  should 
be  elevated  and  an  application  of  a  2  per  cent  solution  of  aluminum 
acetate,  cooled  with  ice,  kept  on  four  hours  every  day,  two  hours  in  the 
forenoon  and  two  hours  in  the  afternoon.  Ice  should  not  be  applied 
directly  to  the  testicle  because  it  might  cause  gangrene. 

In  weakly  persons  this  antiphlogistic  treatment  should  be  continued 
until  the  swelling  has  completely  subsided.  The  diet  should  be  light 
and  the  bowels  kept  regular.  Twice  a  day  0.75  [10  grains]  of  salicylic 
acid  may  be  given,  or  small  doses  of  antipyrin  may  be  used  instead, 
1.0  [15  grains]  being  taken  during  twenty-four  hours.     Both  of  these 


EPIDIDYMITIS.  437 

drugs  exert  a  favorable  effect  upon  the  patient's  constitutional  condi- 
tion.    At  night  the  testicles  should  be  elevated  by  means  of  a  bandage. 

In  other  cases,  especially  in  strong,  robust  persons,  treatment  by 
compression  may  be  tried.  For  this  purpose  a  properly  fitting  suspen- 
sory bandage  gives  the  best  results.  There  are  many  of  these  bandages 
on  the  market,  but  the  Zeissl-Langlebert  has  proved  best  in  my  experi- 
ence. I  have  had  small  hooks  and  eyes  attached  to  it  so  that  the 
testicle  can  be  better  elevated.  [Martin's  epididymitis  bag,  which  is 
made  by  Lentz  and  Sons,  of  Philadelphia,  is  a  very  satisfactory 
American  appliance.]  Compression  is  not  so  useful  as  suspension, 
which  secures  both  elevation  and  rest  for  the  testicle. 

After  the  skin  has  been  lightly  annointed  with  lanolin,  the  sus- 
pensory bandage  is  lined  with  soft  cotton  of  good  quality  and  so 
adjusted  as  to  raise  the  scrotum  slightly  toward  the  abdomen.  It  is 
kept  on  for  four  or  five  days  and  then  changed.  As  the  swelling 
subsides  the  degree  of  suspension  may  be  lessened;  this  is  accomplished 
by  adjusting  the  bandage  more  loosely  and  placing  less  cotton  in  it. 

The  results  obtained  by  this  method  are  excellent.  Pain  soon  sub- 
sides, and  in  course  of  a  few  days,  after  the  acute  inflammation  and 
swelling  have  abated  and  the  slight  fever  disappeared,  the  patient  may 
be  allowed  to  walk  around  and  fulfill  the  ordinary  duties  of  his  vocation. 
Fricke's  adhesive-plaster  dressing,  as  well  as  Gerson's  bandage,  are  heroic 
appliances  which  it  is  better  not  to  employ;  moreover,  they  are  rendered 
needless  by  the  method  of  suspension  which  has  just  been  described. 

During  an  attack  of  epididymitis  local  treatment  of  the  urethra 
must  be  discontinued.  Neither  the  use  of  instruments  nor  the  employ- 
ment of  injections  is  permissible.  If  the  urethral  discharge  is  florid, 
balsamics  and  diluent  drinks  may  be  given.  Not  until  all  inflamma- 
tion of  the  epididymis  has  completely  subsided  should  anti-gonorrhceal 
treatment  be  resumed. 

The  later  stages  of  epididymitis,  in  which  pain  and  swelling  are  no 
longer  present,  must  not  be  allowed  to  go  untreated,  but  an  attempt 
be  made  to  secure  resolution  of  the  nodules  which  have  remained  behind. 
Applications  of  iodine-vasogen — which  acts  better  than  tincture  of 
iodine — or  a  lanolin  ointment  containing  2  per  cent  of  iodine  and  10 
per  cent  of  potassium  iodide  should  be  kept  up  for  months.  [I  have 
obtained  good  results  with  oleate  of  mercury.]  Warm  moist  Priess- 
nitz's  compresses  applied  under  the  suspensory  bandage  also  have 
a  good  effect.     I  have  never  seen  any  good  effects  from  the  use  of 


438  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

electricity,  which  has  been  employed  for  the  purpose  of  causing  absorp- 
tion of  the  remaining  infiltrate. 

DEFERENITIS  OR  FUNICULITIS. 

Inflammation  of  the  vas  deferens  seldom  occurs  as  an  isolated  lesion, 
but  is  generally  associated  with  gonorrhceal  epididymitis  or  sperma- 
tocystitis.  The  vas  can  be  felt  as  a  hard  cord  resembling  a  quill; 
it  can  be  rolled  between  the  fingers  and  traced  to  the  swollen  epidid- 
ymis. In  this  case  the  inflammation  from  the  urethra  extends  by 
continuity  into  the  ejaculatory  duct  and  thence  upwards  into  the  vas 
deferens.  In  case  of  traumatic  epididymitis  complicated  with  defer- 
enitis  the  reverse  of  this  process  obtains,  the  inflammation  extending 
downwards  from  the  epididymis  into  the  vas. 

It  has  often  been  observed  that  epididymitis  may  complicate  gon- 
orrhoea without  the  vas  deferens  being  involved.  In  reality  this 
freedom  of  the  latter  structure  is,  as  a  rule,  merely  apparent.  A  per- 
ceptible and  palpable  swelling  does  not  always  occur,  but  notwith- 
standing this  the  vas  deferens  is  nevertheless  involved,  as  is  proved 
by  the  fact,  that  in  those  affections  in  which  no  symptoms  of  deferenitis 
are  manifest  objective  changes  are  found  in  the  vas. 

Deferenitis  requires  no  special  consideration,  because  it  almost 
always  ends  with  the  epididymitis,  which  with  very  few  exceptions  is 
an  entirely  benign  disease.  Swelling  and  induration  subside  simul- 
taneously with  the  pain.  It  is  only  when  symptoms  of  peritoneal 
irritation,  such  as  colic  and  vomiting,  develop  that  the  disease  becomes 
serious.  Such  symptoms  are  due  to  the  compression  to  which  the 
cord  is  subjected  owing  to  its  swollen  condition.  As  the  swelling 
subsides  spontaneously  we  may  rest  at  ease,  and  not  be  prevailed  upon 
to  operate  by  the  fear  that  the  condition  is  strangulated  hernia, 
which,  as  is  known,  gives  rise  to  similar  symptoms. 

Only  when  there  is  reason  to  believe  that  suppuration  in  the  region 
of  the  peritoneum  will  follow,  is  there  any  ground  for  interference. 
Such  an  occurrence  is  to  be  feared  when  high  fever,  chills,  and  fluctu- 
ation of  the  cord  are  present,  when  pus  is  obtained  by  puncture,  and 
when  the  symptoms  do  not  yield  to  antiphlogistic  treatment.  Under 
these  circumstances  intervention  must  be  practised,  because  peri- 
tonitis may  result  if  the  suppuration  is  allowed  to  extend.  The 
focus  of  suppuration  must  be  sought  out,  and  if  it  is  necessary  to  open 
the  inguinal  canal  to  reveal  it,  no  hesitancy  should  be  felt  in  so  doing. 


ACUTE    HYDROCELE.  439 

After  the  abscess  has  been  emptied  and  an  antiseptic  dressing  applied, 
the  danger  will  be  overcome. 

ACUTE  HYDROCELE. 

Acute  inflammation  of  the  tunica  vaginalis  propria  is  generally 
caused  by  trauma ;  less  frequently  extension  of  inflammation  from  the 
urethra  or  bladder — usually  gonorrhoea — is  responsible,  and  in  ex- 
ceptional cases  it  is  metastatic  in  origin. 

According  to  the  character  of  the  exudate,  we  distinguish  serous, 
fibrinous  or  plastic,  and  purulent  acute  hydrocele.  The  first  is  usually 
a  complication  of  gonorrhoea;  the  last  often  follows  injury,  as  for 
example,  puncture  of  a  hydrocele,  but  it  also  may  develop  in  an  old 
hydrocele  without  any  apparent  cause. 

Owing  to  the  rapid  effusion  of  fluid  between  the  layers  of  the  tunic, 
swelling  of  the  scrotum  rapidly  develops,  so  that  a  transparent  fluctuat- 
ing tumor  is  formed;  considerable  constitutional  disturbance,  such  as 
fever,  depression  and  pain,  is  present.  The  testicle  lies  behind  the 
tumor.  In  the  very  rare  fibrinous  form,  in  which  flakes  and  granules 
of  fibrin  are  precipitated,  crepitation  can  be  plainly  felt.  The  purulent 
form  is  characterized  by  severe  pain,  absence  of  translucency,  and 
severe  constitutional  symptoms. 

All  these  forms  are  benign.  The  serous  form  subsides  in  one 
or  two  weeks,  the  exudate  being  absorbed.  Occasionally  it  becomes 
chronic.  The  fibrinous  form  leads  to  agglutination  and  adhesion  of 
the  two  layers  within  a  short  time.  The  termination  of  the  purulent 
form  is  less  favorable.  The  tunica  vaginalis  almost  always  becomes 
adherent  to  the  superficial  layers  of  the  scrotum,  which  become  inflamed 
and  suppurate,  with  the  result  tat  the  pus  breaks  through  the  skin. 

The  treatment  of  the  first  two  forms  consists  in  rest,  elevation  of  the 
penis,  cool  applications,  and,  as  soon  as  the  most  acute  symptoms 
have  passed,  the  employment  of  slight  compression.  Great  care 
must  be  taken,  however,  in  using  compression.  Fricke's  plaster 
dressing  is  to  be  avoided  for  the  reason  that  it  may  produce  excoria- 
tion and  eczema,  and  perhaps  even  gangrene  of  the  scrotum.  Pres- 
sure is  best  made  by  means  of  good  soft  cotton  placed  in  a  large 
suspensory  bandage.  For  this  purpose  the  well-known  Zeissl-Langle- 
bert  suspensory,  to  which  I  have  added  hooks  and  eyes,  is  very  satis- 
factory. Before  it  is  applied  the  skin  of  the  entire  scrotum  is  greased 
with  lanolin  cream. 


44Q 


TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 


Puncture  is  seldom  necessary  in  the  serous  form;  the  above  mentioned 
measures  are  nearly  always  successful.  If  the  exudate  is  not  entirely 
absorbed  then  the  hydrocele  may  be  punctured  and  from  i  to  3  cm. 
[1 5  to  45  minims]  of  a  mixture  of  equal  parts  of  carbolic  acid  and  glycerine 
injected.     In  the  purulent  form  incision  is  to  be  preferred  to  puncture. 

If  any  of   the  above  named  causes  result  in  an  effusion  of   fluid 


Fig.  206. — Hydrocele. 

along  the  vas  deferens,  the  condition  is  known  as  acute  hydrocele 
of  the  cord.  It  is  very  rare,  and  when  it  does  occur  is  usually  due  to 
acute  inflammation  of  an  already  existing  hydrocele  of  the  cord.  The 
exudate  may  be  serous,  fibrinous,  or  purulent. 

CHRONIC  HYDROCELE. 

Hydrocele,    also   called   periorchitis   and   vaginalitis,    is   the   most 
frequent  affection  of  the  scrotum.     It  is  a  collection  of  fluid  in  the 


CHRONIC    HYDROCELE. 


441 


cavity  of  the  tunica  vaginalis  propria.  As  a  cause  we  have  already 
recognized  the  transition  of  acute  into  chronic  hydrocele;  we  know, 
furthermore,  that  various  injuries  of  the  testicle  are  followed  by  a 
gradual  outpouring  of  fluid  into  the  tunica  vaginalis;  next  to  these 
causes  gonorrhoea  is  the  most  common  cause,  agonorrhceal  epididymitis 
representing  the  connecting  link  between  the  two  diseases.  Other 
diseases  of  the  testicle,  for  example,  syphilis  and  new  growths,  act  as 
predisposing  causes,  and,  finally,  it  must  be  stated  that  there  are  cases 
in  which  no  cause  can  be  determined. 

Hydrocele  is  characterized  by  its  pear-shaped  form.  The  stem  of 
the  pear  lies  at  the  inguinal  ring  and  its  body  is  directed  downwards 
(Fig.  206).  The  tumor  generally  ends  abruptly  at  the  inguinal  ring, 
only  exceptionally  entering  the  canal. 

In  size  it  may  be  as  large  as  a  man's  head,  and  reach  below  the  knee. 
It  is  said  that  as  much  as  twenty  liters  [5  gallons]  of  fluid  have  been 
obtained  from  one  hydrocele. 

As  the  tumor  is  composed  of  fluid  it  is  relatively  lighter  than  solid 
tumors  of  the  same  size.  The  position  of  the  testicle 
is  determined  by  the  collection  of  fluid.  If  it  were 
not  previously  adherent  to  surrounding  parts,  it 
will  lie  in  the  lower  and  posterior  portion  of  the 
scrotum  (Fig.  207),  the  tunic  rising  above  owing  to 
its  distention  by  the  fluids. 

Other  important  characteristics  of  the  tumor  are 
its  fluctuation  and  translucency.  Fluctuation,  how- 
ever, may  be  indistinct  if  the  tunic  is  filled  very 
full  or  its  walls  thickened.     At  first  the  serous  wall     Fig.  207.— The  tes- 

r  .-,       .       .     .  1  1    t      ,  •        Till  i        •.    tide  lies  below  and 

of  the  tunic  is  not  changed,  but  m  old  hydroceles  it  behind. 
becomes  thickened    and    indurated,    resembling    a 
rind,  and  may  be  partly  calcified  or  ossified. 

The  translucency  is  due  to  the  fact  that  the  contents  of  the  tumor  is 
ordinary  serum,  such  as  is  found  in  ascites  and  hydrothorax.  In  this 
serum  shining  crystalline  plates  of  cholesterin  may  usually  be  found; 
they  contain  a  high  percentage  of  albumen.  Owing  to  discoloration 
of  this  fluid,  as  well  as  to  thickening  of  the  walls  of  the  hydrocele, 
translucency  may  entirely  disappear,  a  fact  which  it  is  important  to 
know  as  regards  diagnosis. 

Discoloration  of  hydrocele  fluid  is  often  observed  in  cases  of  long 
standing.     It  then  becomes  dark  yellow  or  brown,  and  loses  its  limpid- 


442  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

ity.  This  change  is  particularly  favored  by  repeated  puncture  of  the 
sac,  which  allows  the  coloring  matter  of  the  blood  to  mix  with  the 
serum.  Other  non-translucent  collections  of  fluid  in  the  tunica 
vaginalis,  namely,  spermatocele  and  hematocele,  will  be  considered 
later. 

A  process  in  which  both  discoloration  of  the  serous  fluid  and  changes 
in  the  wall  of  the  sac  occur,  has  been  described  under  the  name  of 
fibrinous  hydrocele.  As  the  result  of  a  peculiar  inflammatory  process 
a  fibrinous  exudation  takes  place,  some  of  the  fibrin  being  deposited 
upon  the  internal  walls  of  the  hydrocele  and  some  being  taken  up  by 
the  fluid.  When  the  connection  between  the  wall  and  the  fibrinous 
deposit  becomes  thinner,  owing  to  shrinkage  and  contraction,  a  pedun- 
culated tumor  is  gradually  formed.  The  peduncle  may  become 
separated  from  the  wall  and  thickening  of  the  latter  occur,  so  that  upon 
palpation  it  may  seem  as  though  a  solid  tumor  were  present,  but 
crepitation  of  the  detached  mass  of  fibrin  will  lead  to  a  correct  differ- 
ential diagnosis. 

As  a  rule,  hydrocele  does  not  produce  any  symptoms  other  than  those 
due  to  its  size.  Thus  it  happens  that  as  long  as  the  tumor  remains 
small  it  is  generally  not  noticed  by  the  patient,  attention  being  attracted 
to  it  only  when  it  becomes  large  and  heavy  enough  to  cause  traction  on 
the  cord  and  so  produce  discomfort. 

As  the  tumor  grows  the  difficulty  increases.  The  sac  encroaches 
upon  surrounding  tissues,  the  space  for  the  other  testicle  becomes  too 
small,  the  skin  of  the  penis  is  trespassed  upon,  so  that  the  organ  shrivels 
and  is  pushed  to  one  side,  with  the  result  that  cohabitation  is  often 
rendered  impossible.  During  micturition  wetting  of  the  skin  is 
unavoidable,  and  frequently  gives  rise  to  very  troublesome  eczema. 
Other  ill  effects  are  gradual  atrophy  of  the  testicle  owing  to  pres- 
sure of  the  fluid  upon  it,  and  the  development  of  hernia.  The  latter 
occurrence  is  explained  by  the  traction  which  the  hydrocele  exerts 
upon  the  peritoneum,  with  which  the  tunica  vaginalis  is  adherent. 

In  regard  to  the  course  of  hydrocele,  it  may  be  stated  that  the  tumor 
seldom  remains  of  the  same  size,  but  generally  becomes  larger  and 
larger,  attaining  dimensions  which  cause  it  to  become  unendurable. 
In  many  cases,  however,  its  progress  is  interrupted  by  periods  of 
quiescence.  Unless  the  greatly  distended  sac  bursts,  an  occurrence 
which  has  been  observed  only  a  few  times,  the  patient  is  forced  to 
seek  relief  from  the  surgeon. 


CHRONIC    HYDROCELE.  443 

Occasionally,  instead  of  being  pear-shaped,  a  hydrocele  may  resemble 
an  hour-glass,  being  constricted  at  the  inguinal  canal.  Two  sacs 
are  then  present,  communicating  with  one  another  through  a  fine 
opening;  both  may  be  in  the  scrotum,  or  one  may  be  in  the  scrotum 
and  one  in  the  abdomen.  When  the  latter  condition  obtains  we  have  a 
bilocular  hydrocele.  The  fluid  can  be  pressed  out  of  one  sac  into  the 
other.  Both  sacs  are  translucent.  Less  frequently  there  are  several 
divisions  of  the  tumor,  constituting  a  multilocular  hydrocele.  Hydro- 
cele may  also  be  associated  with  cystoma  of  the  testicle. 

The  most  important  complication  is  hernia.  Serous  effusion 
into  a  hernial  sac  may  occur  as  well  as  hernia  in  association  with 
true  hydrocele  (Konig).  If  the  hernia  reaches  far  down  it  usually 
lies  behind  the  hydrocele. 

In  regard  to  diagnosis,  it  may  be  stated  that  while  some  cases  are 
very  easy  to  recognize  others  may  be  most  difficult.  Great  care  must 
be  given  to  differentiating  between  hydrocele  and  scrotal  hernia, 
a  correct  diagnosis  being  of  the  utmost  importance. 

If  tympany  be  elicited  upon  percussion  of  the  tumor,  hydrocele  is 
out  of  the  question.  Epiplocele  as  well  as  enterocele  which  does  not 
contain  gas  may,  however,  emit  a  dull  note.  Palpation  of  a  hydrocele 
reveals  it  to  be  a  fluctuating  tumor  having  a  smooth  regular  surface, 
such  as  is  never  presented  by  a  scrotal  hernia.  Hydrocele  is  usually 
translucent,  hernia  never.  Cough  has  no  effect  upon  the  size  of  a 
hydrocele;  when  the  patient  is  in  the  horizontal  position  its  size 
is  not  altered;  pressure  is  not  painful,  and  the  tumor  cannot  be 
reduced. 

Between  the  highest  part  of  a  hydrocele  and  the  inguinal  ring  is  a 
space  into  which  the  finger  can  be  inserted  and  its  tip  carried  into  the 
inguinal  ring,  where  nothing  but  the  cord  will  be  felt;  no  protrusion 
will  occur  when  the  patient  coughs.  There  are  exceptional  cases, 
as  has  already  been  stated,  in  which  the  hydrocele  extends  into  the 
inguinal  canal,  but,  as  a  rule,  this  is  not  the  case;  moreover,  hydrocele, 
in  contradistinction  to  hernia,  develops  from  below  upwards. 

Hydrocele  differs  from  tumors  of  the  testicle  and  epididymis  in  that 
it  has  a  fairly  regular  pyriform  shape,  whereas  tumors  form  an  irregular 
mass  in  the  scrotum.  With  the  exception  of  cysts  tumors  are  also  not 
transparent,  nor  are  they  so  tense  as  hydrocele;  moreover,  they  are 
sensitive  to  pressure,  while  hydrocele  ,  as  is  well-known,  may  be  pressed 
upon  without  any  pain  being  caused. 


444 


TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 


The  last  characteristic  is  a  valuable  diagnostic  point  in  distinguishing 
hydrocele  from  inflammatory  diseases  of  the  testicle  and  epididymis. 

The  consideration  of  all  these  circumstances  will  in  most  cases  lead 
to  the  determination  of  a  correct  diagnosis.  As  a  last  resort  puncture 
with  a  fine  needle  is  permissible,  and  may  be  considered  safe. 

As  concerns  treatment,  it  is  first  of  all  important  to  understand  that 
hydrocele  will  not  undergo  spontaneous  cure,  but,  on  the  contrary, 
will  be  almost  certain  to  become  larger.  It  is  only  when  the  hydrocele 
remains  unchanged  in  size — which  is  rare — and  is  not  large  enough 
to  annoy  the  patient,  that  it  may  be  allowed  to  remain  untreated. 


Fig.  208. — Tapping  a  hydrocele  according  to  Kocher's  method. 
a.  Direction  of  the  trocar  when  the  puncture  is  made.  b.  Direction 
when  the  fluid  is  withdrawn,  c.  Hydrocele,  d.  Epididymis,  e.  Testis. 
(Konig.) 


Internal  medication  and  local  applications  of  liniments  and  oint- 
ments are  without  result ;  therefore  they  may  be  dismissed  from  consider- 
ation without  further  mention.     Treatment  must  be  entirely  surgical. 

The  simplest  way  is  to  tap  the  sac  with  a  fine  trocar.  After  being 
carefully  disinfected,  the  scrotum  is  so  held  in  the  left  hand  that  its 
posterior  surface,  together  with  the  testicle,  lies  in  the  hollow  of  the  palm. 

The  trocar  is  then  plunged  in  perpendicularly  to  the  long  axis  of 
the  scrotum.     This  manner  of  making  the  puncture  is  important,  for 


CHRONIC    HYDROCELE.  445 

if  it  be  practised  otherwise  the  needle  may  be  carried  between  the 
tissues  of  the  scrotum.  After  withdrawal  of  the  stilet  the  canula  is 
lowered  (Fig.  208)  and  the  serum  begins  to  flow  out.  Tapping  can 
be  performed  repeatedly  without  any  damage.  I  have  punctured  a 
hydrocele  twenty  times  for  a  patient  who  was  unwilling  to  have  a 
radical  operation  performed,  tapping  it  once  or  twice  every  year. 

From  what  has  already  been  stated  it  will  be  understood  that  tapping 
is  solely  a  palliative  measure,  and  that  the  tunica  vaginalis  will  slowly 
fill  up  again  after  its  contents  have  been  withdrawn.  It  is  only  in 
children — and  exceptionally  in  adults — that  the  irritation  of  the  punc- 
ture results  in  sufficient  inflammation  to  cause  adhesion  of  the  layers 
of  the  tunica  and  thus  obliterate  the  cavity  so  that  the  hydrocele 
cannot  recur. 

A  procedure  which  may  be  combined  with  tapping  is  the  injection 
of  irritating  substances  through  the  canula  after  the  fluid  has  been 
withdrawn.  Among  those  which  have  been  employed  are  alcohol, 
chloroform,  ether,  and  tincture  of  iodine;  recently  a  mixture  of  equal 
parts  of  glycerine  and  concentrated  carbolic  acid  has  been  more  com- 
monly used  than  these  other  substances. 

The  procedure  is  very  simple  and  in  many  cases  results  in  cure,  but 
it  is  not  absolutely  certain  nor  entirely  without  danger.  A  day  or  two 
after  the  injection  the  inflammatory  process  begins  to  manifest  itself. 

The  patient  complains  of  more  or  less  pain  in  the  testicle,  and  the 
tissues  around  the  gland  begin  to  swell ;  elevation  of  temperature  is  not 
uncommon.  All  these  phenomena,  however,  usually  subside  within 
a  few  days,  and  within  a  week  or  two  recovery  is  complete. 

There  may,  however,  be  a  different  termination.  Severe  suppurative 
inflammation  with  liberation  of  the  pus  externally  may  occur,  or  the 
suppuration  may  invade  the  testicle.  I  have  also  seen  recurrence 
of  the  hydrocele  follow  this  method. 

Therefore  I  favor  the  radical  operation  by  means  of  open  incision, 
and  of  the  various  methods,  I  prefer  that  of  Volkmann.  Skin  and 
hydrocele-sac  are  incised,  the  tunica  vaginalis  sewed  to  the  skin  on 
each  side  with  catgut,  and  then  the  edges  of  the  wound,  with  the 
exception  of  a  small  cleft  which  is  left  open  at  the  lower  angle,  are 
closed  with  a  few  interrupted  silk  ligatures,  care  being  taken  to  bring 
the  serous  surfaces  of  the  hydrocele  walls  into  close  apposition.  When 
the  tissues  are  cut  through  all  haemorrhage  must  be  arrested,  because 
otherwise  a  haematoma  may  form  which  may  suppurate  and  retard 


446  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

healing.  This  is  the  only  danger  of  the  operation.  I  never  saw  any 
accident  happen  except  this  one. 

Cure  is  effected  by  adhesion  of  the  two  layers  of  the  tunica  vaginalis 
which  are  brought  closely  together.  Recurrence  is  thus  practically 
impossible,  although  now  and  then  one  may  happen.  In  my  own 
experience  none  have  occurred. 

Von  Bergmann  recommended  the  extirpation  of  the  tunica  vaginalis, 
either  in  its  entirety  or  up  to  the  cord,  with  suture  of  the  cut  edges  over 
the  testicle.  I  consider  this  method  unnecessary;  if  the  tunica  vaginalis 
is  very  thick  and  large  it  may  be  well  to  cut  off  a  piece. 

Winkelmann's  method  [also  known  as  Doyen's  and  Jaboulay's],  in 
which  the  tunica  vaginalis  is  incised,  turned  inside  out  and  the  edges 
united  by  suture,  I  have  abandoned  as  being  an  unnecessary  procedure. 

GALACTOCELE,  HEMATOCELE  ANDTSPERMATOCELE. 

Galactocele  differs  from  hydrocele  in  that  the  fluid  contained  in  the 
cavity  of  the  tunica  vaginalis  is  milky  instead  of  clear  and  yellow.  It 
is  such  a  rare  affection  that  it  merely  requires  to  be  mentioned.  Vidal 
saw  one  case  in  a  soldier  who  came  to  him  from  Africa.  The  essen- 
tial feature  of  this  case  was  the  excessively  fatty  character  of  the  fluid, 
which,  when  viewed  under  the  microscope,  looked  like  an  emulsion. 
Accordingly  we  may  consider  galactocele  as  a  fatty  hydrocele. 

In  haematocele  the  fluid  which  is  poured  out  into  the  tunica  vaginalis 
is  sanguinolent. 

In  regard  to  the  origin  of  this  affection,  it  is  known  that  a  large 
number  of  cases  result  from  injury;  thus,  for  example,  it  not  uncom- 
monly happens  that  haematocele  follows  repeated  puncture  of  a  hydro- 
cele. Often,  however,  the  causative  injury  passes  unnoticed.  Slight 
traction  upon  or  bruising  of  the  hydrocele,  which  may  not  produce 
pain,  and  therefore  passes  unobserved,  causes  slight  haemorrhage  and 
inflammation  of  the  tunic.  Thickening  of  its  walls  and  alterations 
in  its  blood-vessels  may  also  give  rise  to  bleeding.  Thus,  haematocele 
may  merely  represent  a  metamorphosed  hydrocele. 

Diagnosis  is  not  difficult.  It  may  be  learned  from  the  history  of  the 
case,  or  from  a  previous  observation,  that  a  translucent,  fluctuating 
tumor  was  present  in  the  scrotum.  In  the  absence  of  such  knowledge 
information  must  be  obtained  in  regard  to  the  development  of  the 
tumor— whether  it  was  sudden,  rapid,  or  gradual.  Slow  evolution 
is  by  far  the  most  common.     The  smooth  and  sometimes  tense  tumor 


GALACTOCELE,    HEMATOCELE    AND    SPERMATOCELE.  447 

lies  anterior  to  the  testicle  exactly  the  same  as  a  hydrocele.  Trans- 
lucency,  however,  is  absent.  On  account  of  the  thickening  of  the 
wall  fluctuation  is  seldom  demonstrable.  Subjective  symptoms  may 
be  absent,  but  in  some  cases  dragging  pain  is  present. 

The  affection  is  entirely  devoid  of  danger,  although  the  testicle  may 
gradually  atrophy.  For  the  latter  reason  removal  of  the  tumor  is 
indicated. 

This  can  be  effected  only  by  operation.  Compression  by  means  of 
a  suspensory  bandage  lined  with  cotton  will  seldom  accomplish  any- 
thing, and  I  do  not  advise  the  use  of  Fricke's  plaster  dressing.  The 
hematocele  cannot  be  entirely  emptied  by  puncturing  it.  Volkmann's 
operation  for  hydrocele  is  the  appropriate  measure.  Precaution  must 
be  taken  to  empty  the  sac  completely,  and  to  this  end  the  walls  of  the 
hydrocele  must  be  most  carefully  examined. 

Spermatocele  is  to  be  considered  in  a  somewhat  different  light  than 
galactocele  and  haematocele.  It  is  a  cyst-like  tumor  of  the  scrotum 
containing  semen.  Its  development  is  to  be  attributed  to  the  occur- 
rence of  any  inflammatory  process  which  leads  to  the  partial  or 
total  occlusion  of  the  seminiferous  tubules,  so  that  any  semen  which 
may  continue  to  be  secreted  is  retained,  and  thus  gives  rise  to  disten- 
tion of  the  constricted  tubules.  The  tumor  is  thus  a  typical  reten- 
tion-cyst. 

These  spermatoceles  generally  take  origin  at  the  site  where  the  vasa 
efferentia  empty  into  the  epididymis,  that  is,  at  the  point  of  union 
between  the  testicle  and  epididymis.  The  form  and  growth  of  the 
tumor  is  thus  explained  by  its  manner  of  development.  It  may  be 
either  extravaginal  or  intravaginal,  according  as  it  extends  backwards 
and  forwards  or  grows  downwards  into  the  tunica  vaginalis.  If 
growth  occurs  in  an  upward  direction  the  tunica  vaginalis  is  not  dis- 
turbed, so  that  when  the  spermatocele  is  incised  the  former  is  not 
injured.  If  growth  occurs  downwards  and  forwards  the  tunica  is 
carried  before  it,  and  in  this  case  must  be  cut  before  the  wall  of  the 
cyst  can  be  reached.  The  extravaginal  form  of  spermatocele  is  more 
common    than    intravaginal. 

The  fluid  in  the  sac  somewhat  resembles  soap-suds;  it  contains 
albumen  and  spermatozoa. 

It  may  be  impossible  to  diagnosticate  the  intravaginal  form  from 
hydrocele  unless  puncture  be  made;  the  testicle  lies  behind  as  is  the 
case  in  hydrocele;  fluctuation  is  present;  translucency  is  wanting,  but 


448  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

as  it  may  also  be  absent  in  hydrocele  when  the  walls  of  the  sac  are 
thickened,  this  is  a  sign  of  minor  value. 

Extravaginal  spermatocele  is  very  likely  to  be  confused  with  hydrocele 
of  the  cord.  It  forms  a  pyriform  fluctuating  tumor  above  the  testicle, 
along  the  course  of  the  cord.  It  may  be  distinguished  from  hydrocele 
of  the  cord  by  the  fact,  that  the  apex  of  the  latter  tumor  is  above  and 
the  broad  base  below,  whereas  in  hydrocele  the  opposite  condition 
obtains.  Translucency  of  the  hydrocele,  or,  if  this  be  absent,  puncture 
of  the  tumor,  will  assure  diagnosis. 

As  concerns  treatment,  tapping  followed  by  the  injection  of  carbolic 
acid  and  glycerine  in  equal  parts  may  be  practised,  or  the  cyst  may 
be  opened  and  the  edges  sutured  to  the  superficial  structures  as  in  the 
radical  operation  for  hydrocele. 

HYDROCELE  OF  THE  SPERMATIC  CORD,  OR  CYSTIC 
HYDROCELE. 

Hydrocele  of  the  spermatic  cord  occurs  if  a  portion  of  the  vaginal 
process  remains  patent  instead  of  becoming  obliterated  and  a  serous 
effusion  takes  place  into  its  cavity.  If  the  vaginal  process  be  closed 
only  above  at  the  internal  ring  and  below  at  the  upper  part  of  the 
testicle,  the  tumor  will  extend  along  the  cord  as  far  as  the  internal  ring ; 
in  other  cases  when  the  vaginal  process  is  partly  obliterated  smaller 
cysts  are  formed  along  the  course  of  the  cord. 

If  non-union  exists  at  several  places  multiple  cysts  are  formed,  and 
the  condition  is  known  as  multilocular  hydrocele  of  the  spermatic  cord ; 
if  the  cyst  is  divided  into  two  parts  it  is  termed  bilocular. 

Hydrocele  of  the  cord  is  characterized  by  the  fact  that  it  forms 
a  pear-shaped  tumor  the  limits  of  which  may  be  defined  at  the  internal 
abdominal  ring  above  and  the  testicle  below.  It  is  not  reducible, 
undergoes  no  alteration  when  the  patient  changes  position,  is  not 
forced  out  by  coughing,  sneezing,  or  vomiting,  thus  differing  in  all  these 
respects  from  hernia,  from  which  it  will  be  readily  distinguished. 

Fluctuation  cannot  always  be  detected,  because  the  sac  may  be  so 
full  that  the  tumor  is  tense  and  distended;  its  walls  may  also  be  too 
thick  for  the  wave  of  fluid  to  be  transmitted.  For  the  same  reason 
translucency  is  less  marked  than  in  congenital  hydrocele. 

Occasionally  hydrocele  of  the  cord  descends  behind  the  testicle, 
and  in  this  case  may  easily  be  mistaken  for  an  ordinary  hydrocele 
with  abnormal  position  of  the  testis.     These  relations  are  important 


VARICOCELE.  449 

in  regard  to  tapping;  if  the  puncture  should  be  made  in  the  ordinary 
manner  from  before  backwards  the  testicle  would  be  pierced. 

The  cause  of  this  affection  is,  in  some  cases  at  least,  to  be  sought  for 
in  trauma,  which  may  have  been  slight  and  therefore  have  passed 
unnoticed.  More  frequently,  however,  it  is  due  to  a  congenital  con- 
dition in  which  faulty  coalescence  of  the  vaginal  process  is  present 
and  is  followed  by  traumatic  or  inflammatory  effusion. 

It  causes  little  trouble,  and  one  or  more  tappings  will  suffice  to  effect 
a  cure.  As  an  auxiliary  measure  a  small  quantity  of  Lugol's  solution 
or  the  carbolic-glycerine  mixture  may  be  injected. 

Incidentally  we  wish  to  mention  the  cysts  which  develop  from  the 
pedunculated  and  sessile  hydatids  of  Morgagni.  These  small  vesicles 
occasionally  undergo  cystic  dilatation,  becoming  as  large  as  cherries 
or  perhaps  even  attaining  the  size  of  plums.  According  to  Konig, 
these  intravaginal  cysts  occasionally  rupture,  and  being  in  communi- 
cation with  the  tubules  of  the  epididymis  the  result  is  an  outpouring 
of  semen  into  the  cavity  of  the  tunica  vaginalis. 

Different  from  these  are  the  very  rare  cysts  which  develop  in  the 
connective  tissue  of  the  cord.  They  occur  as  single  or  multiple  circum- 
scribed cystic  dilatations  of  the  lymph  vessels  of  the  testicle  and  epidid- 
ymis. 

VARICOCELE. 

Varicocele  is  a  term  applied  to  varicosities  of  the  spermatic  cord  and 
testicle.  Usually  the  distention  is  confined  to  the  veins  of  the  cord; 
more  rarely  those  of  the  testicle  are  involved. 

The  affection  develops  in  adult  life  and  is  essentially  dependent  upon 
anatomical  conditions.  The  spermatic  vein  is  formed  by  the  conflu- 
ence of  the  different  branches  of  the  pampiniform  plexus,  and  ascends 
directly  upwards  as  far  as  the  second  lumbar  vertebra,  so  that  when 
the  body  is  in  the  upright  position  the  pressure  of  a  moderately  high 
column  of  blood  is  brought  to  bear  upon  the  plexus  (Bardeleben). 

The  greater  frequency  of  varicocele  on  the  left  side  may  be  explained 
by  the  fact  that  the  left  spermatic  vein  empties  into  the  renal  vein  at 
a  right  angle,  whereas  the  right  spermatic  vein  empties  directly  into  the 
inferior  vena  cava  at  an  acute  angle.  Owing  to  these  conditions  there 
is  more  resistance  to  the  emptying  of  the  blood  from  the  left  spermatic 
vein  than  from  the  right. 

The  pressure  exerted  upon  the  left  vein  by  the  distended  sigmoid 


450  TESTICLES,    EPIDIDYMIS    AND    SPERMATIC    CORD. 

flexure  has  also  been  designated  as  a  causative  factor.  If,  in  addition 
to  these  conditions,  it  be  remembered  that  the  left  testicle  generally 
hangs  lower  than  the  right,  as  a  result  of  which  its  vessels  are  longer, 
and  that  owing  to  sexual  excitement  there  is  a  frequent  afflux  of  blood 
to  the  veins  of  the  cord,  the  origin  of  the  affection  will  be  understood 
without  further  explanation. 

Symptoms  may  be  entirely  wanting  or  again  may  be  of  considerable 
severity.  In  the  majority  of  cases  I  have  not  seen  any  great  disturbance. 
The  traction  exerted  upon  the  testicle  is  uncomfortable,  and  upon 
exertion  the  discomfort  may  amount  to  a  dull,  dragging  pain.  Rarely 
very  severe  pain  may  be  present.  The  patient  is  usually  at  ease  when 
he  is  lying  down  or  sitting,  the  pain  coming  on  after  violent  exertion 
or  walking. 

The  disease  may  remain  stationary  for  years,  the  patient  experienc- 
ing no  trouble  except  an  occasional  uncomfortable  dragging  sensation. 
The  varicosity,  however,  does  not  become  any  larger.  Distention  of 
the  vessels  varies  according  as  the  upright  or  recumbent  posture  is 
assumed;  they  become  filled  when  the  patient  stands  and  empty 
themselves  when  he  lies  down.  They  can  also  be  filled  by  rubbing 
them  in  a  downward  direction  and  emptied  by  stroking  them  in  an 
upward  direction. 

Inspection  alone  is  usually  sufficient  for  a  diagnosis  and  palpation 
renders  it  certain  in  every  case.  There  is  diffuse  swelling  of  the 
affected  half  of  the  scrotum  and  it  is  lengthened  and  thickened;  the 
veins  are  tortuous  and  dilated,  and  when  rolled  between  the  fingers 
feel  like  a  mass  of  earthworms.  Periphlebitic  areas  with  thickening 
of  the  vessel- walls  may  also  be  detected. 

The  course  of  the  disease  is  entirely  benign  and  does  not  endanger 
life.  The  condition  sometimes  requires  to  be  remedied,  however,  as 
the  pressure  to  which  the  testicle  is  subjected  may  cause  it  to  atrophy. 
Interference  is  indicated  particularly  when  the  affection  is  bilateral. 
Otherwise  it  is  only  exceptional  cases,  in  which  unbearable  pain  annoys 
the  patient,  that  will  demand  intervention. 

In  mild  cases  treatment  consists  in  removing  the  traction  which  the 
testicle  exerts  upon  the  cord  by  having  the  patient  wear  a  well-fitting 
suspensory  bandage.  In  numerous  cases  of  mine  this  has  succeeded 
in  entirely  removing  all  the  discomfort  which  my  patients  experienced. 
I  do  not  consider  it  advisable  to  employ  compression,  and,  moreover, 
deem  it  useless.     There  is,  of  course,  no  objection  to  padding  the 


VARICOCELE.  451 

suspensory  lightly.  The  scrotum  may  also  be  frequently  washed 
with  cool  water,  which  at  all  events  can  do  no  harm. 

The  bowels  should  be  regulated  and  the  rectum  kept  free  from 
scybalae,  so  that  pressure  will  not  be  exerted  upon  the  veins. 

Cure  is  to  be  expected  only  by  a  radical  operation.  Many  procedures 
which  were  formerly  practised,  such  as  galvano-puncture,  compression 
even  to  the  point  of  gangrene,  removal  of  a  portion  of  the  scrotum 
with  the  idea  that  the  resulting  contraction  would  shorten  the  veins, 
and  subcutaneous  uncoiling  and  ligation  of  single  veins  have  been 
entirely  abandoned.  If  operation  is  indicated  at  all  the  only  thing 
to  be  considered  is  to  lay  bare  the  veins  and  ligate  them  under  the 
guidance  of  the  eye. 

The  pampiniform  plexus  is  exposed — and  to  this  end  it  is  better 
to  operate  with  the  patient  in  the  sitting  posture  so  that  the  veins  may 
be  well  distended — and  the  arteries  and  vas  deferens  carefully  and 
cautiously  separated;  the  spermatic  artery  must  be  handled  cautiously 
for  the  reason  that  even  the  slightest  injury  to  it  may  result  in  gangrene 
of  the  testicle.  The  veins  thus  isolated  are  tied  above  and  below  and 
the  portion  between  the  ligatures  cut  out.  At  first  reactive  inflam- 
mation sets  in,  but  it  soon  subsides.  Healing  of  the  wound  always 
follows.  I  have  never  seen  any  complications  ensue.  As  already 
stated,  it  is  only  in  exceptional  cases  that  operation  is  necessary. 
Usually  the  wearing  of  a  suspensory  bandage  will  suffice.  [In  operating 
for  varicocele  it  is  my  practice  to  cover  the  divided  ends  of  the  veins 
with  fascia,  using  the  finest  catgut  for  suturing,  and  then  to  bring  them 
into  apposition  by  tying  the  ligatures  together.  Varicocele  may  also 
be  operated  upon  by  making  an  incision  over  the  external  abdominal 
ring,  drawing  up  the  cord  and  then  excising  the  veins  in  the  usual 
manner.     This  method  was  introduced  by  Bloodgood.] 


31 


452  DISEASES    OF    THE    SEMINAL    VESICLES. 


DISEASES  OF  THE  SEMINAL  VESICLES. 
ANATOMY  AND  PHYSIOLOGY. 

The  seminal  vesicles,  which  develop  from  the  Wolfian  bodies,  are 
two  sausage-shaped  expansions  of  the  vasa  deferentia,  placed  symmet- 
rically upon  the  floor  of  the  pelvis.  From  the  vasa  deferentia  they 
extend  lateralwards  and  upwards  on  each  side,  forming  an  angle 
of  about  450.  They  are  about  5  cm.  [2  inches]  long,  2  cm.  [f  of  an 
inch]  wide  and  1  cm.  [f  of  an  inch]  thick.  They  are  enclosed  in  a 
sort  of  a  capsule  made  up  of  strong  connective  tissue,  and  have  a  rough 
surface. 

The  seminal  vesicles  lie  with  their  posterior  surface  placed  against  the 
rectum  and  their  anterior  against  the  bladder.  Internally  they  are  in 
relation  with  the  vasa  deferentia  and  below  with  the  prostate.  The 
peritoneum  covers  only  their  upper  surface.  It  passes  from  the 
bladder  to  the  upper  part  of  the  seminal  vesicles,  descends  between 
the  rectum  and  bladder  and  again  proceeds  upwards  from  the  rectum. 
That  portion  of  the  bladder  lying  between  the  seminal  vesicles  and 
not  covered  by  peritoneum,  sometimes  called  the  trigonum  inter  dej- 
erentiale,  varies  in  size:  the  fuller  the  bladder  the  higher  the  perito- 
neum will  rise,  and  consequently  the  greater  the  free  surface  will 
become. 

The  secretion  of  the  seminal  vesicles  is  golden-yellow  in  color, 
contains  albumen  and  almost  without  exception  spermatozoa.  For 
a  long  time  no  uniformity  of  opinion  has  prevailed  concerning  the 
nature  of  this  secretion  and  the  function  of  the  seminal  vesicles.  A 
few  investigators  have  maintained  that  the  semen  is  fully  elaborated 
in  the  testicles  and  that  it  is  merely  stored  up  in  the  seminal  vesicles, 
from  which  it  is  expelled  when  ejaculation  occurs.  Others  have  held 
to  the  opinion  that  the  seminal  vesicles  are  not  only  receptacles  for  the 
semen,  but  that  they  also  produce  a  specific  secretion,  which  comes 
from  certain  sinus-like  depressions  in  the  mucosa,  known  as  glands, 
although  Waldeyer  and  Kolliker  do  not  consider  them  to  be  such. 

This  latter  difference  of  opinion  is  not  of  importance,  for,  as  is  well 
known,  the  epithelium  of  the  mucous  membrane  can  produce  a  secre- 
tion.    The  seminal  vesicles,  then,  may  be  said  to  elaborate  a  specific 


EXAMINATION    OF    THE    SEMINAL    VESICLES.  453 

secretion,  which,  according  to  Virchow,  is  a  proteid  compound;  it  is 
insoluble  in  water,  but  dissolves  readily  in  acetic  acid  and  a  solution  of 
potassium  f errocyanide ;  when  warm  it  is  liquid,  but  when  cold  it 
becomes  gelatinous  in  consistency.  That  this  secretion  is  derived 
from  the  seminal  vesicles  is  attested  by  the  fact,  that  it  can  be  sepa- 
rated from  the  testicular  secretion  and  its  differences  from  the  latter 
proved  by  chemical  analysis. 

Adopting  the  results  of  Rehfisch's  diligent  investigations  it  may  be 
stated  that  the  seminal  vesicles  produce  a  specific  secretion;  that  the 
spermatozoa  bear  a  definite  though  as  yet  unknown  relation  to  this 
secretion;  that  a  sufficiently  large  quantity  of  semen  for  an  ejaculation 
is  stored  up  in  them,  and  that  the  musculature  of  their  walls  plays  an 
important  role  in  the  production  of  ejaculation. 

The  arteries  of  the  seminal  vesicles  are  derived  from  the  middle 
hemorrhoidal,  internal  pudic,  deferential,  inferior  vesical  and  internal 
iliac.  The  veins  empty  into  the  internal  iliac  vein.  The  lymphatic 
vessels  discharge  into  the  glands  of  the  rectum  and  those  at  the  inlet 
of  the  pelvis. 

EXAMINATION  OF  THE  SEMINAL  VESICLES  AND  THEIR 

SECRETION. 

Examination  of  the  seminal  vesicles  is  difficult  because  of  their 
concealed  position.  If  the  surgeon's  finger  is  long  and  the  patient  not 
too  fat,  rectal  examination  may  reveal  the  presence  of  a  gut-like, 
soft,  doughy  body  about  the  size  and  length  of  a  finger  on  either  side 
of  the  prostate.  They  diverge  upwards  and  may  be  distinguished 
from  the  prostate  by  their  uneven  surface.  In  numerous  cases,  however, 
they  cannot  be  felt  under  ordinary  circumstances,  it  being  necessary 
to  induce  ansesthesia  before  the  finger  can  be  carried  sufficiently  high 
in  the  rectum  to  palpate  them. 

To  obtain  their  secretion  the  seminal  vesicles  must  be  massaged. 
This  can  be  done  properly  only  when  they  can  be  palpated  in  their 
entirety,  for  if  only  the  lower  portion,  just  above  the  prostate,  can  be 
reached,  they  are  not  accustomed  to  empty  themselves. 

Their  contents  may  appear  at  the  external  meatus  or  flow  back 
into  the  bladder.  In  the  latter  case  the  patient  is  told  to  urinate  and 
the  product  is  then  recovered  from  the  urine;  or,  if  this  does  not  suc- 
ceed, the  bladder  may  be  filled  with  sterile  water  and  the  contents  then 


4.54  DISEASES    OF    THE    SEMINAL    VESICLES. 

withdrawn.  The  semen  will  appear  in  the  water  as  sausage-shaped, 
translucent  masses. 

Microscopically  many  motionless  spermatozoa  may  be  perceived 
in  a  pellucid  filamentous  stroma. 

If  the  contents  cannot  be  expressed  in  this  manner,  there  is  nothing 
to  do  but  anaesthetize  the  patient  and  then  introduce  the  finger  into  the 
rectum,  or  better  still  to  use  Felecki's  metal  instrument,  which  is 
a  pyriform  bulb  placed  at  a  right  angle  upon  a  long  handle.  With 
this  instrument  pressure  can  be  made  upon  the  seminal  vesicles  without 
difficulty,  so  that  their  contents  will  be  expelled. 

Because  of  the  inaccessibility  of  the  seminal  vesicles  diseases  affecting 
them  are  rarely  diagnosticated.  They  are  subject  to  malformation, 
injury,  acute  and  chronic  inflammation,  tuberculosis,  abscess,  cysts 
and  hydrocele,  concretions,  and,  finally,  sarcoma  and  carcinoma. 

MALFORMATIONS  OF  THE  SEMINAL  VESICLES. 

Absence  of  both  seminal  vesicles  is  due  to  an  arrest  of  develop- 
ment. The  testicles  may  also  be  absent  or  atrophied;  in  case  they 
are  well  developed  there  are  other  defects  in  the  urogenital  apparatus. 
Thus,  the  bladder  or  prostate  may  be  absent,  a  kidney  may  be  wanting, 
the  anus  be  imperforate,  exstrophy  of  the  bladder  may  be  present, 
or  the  entire  sexual  apparatus  may  be  absent. 

Absence  of  one  seminal  vesicle  is  more  common  than  absence  of 
both.  In  such  cases  there  are  usually  other  defects  in  the  same  side 
of  the  genital  apparatus,  the  corresponding  testicle,  kidney,  ureter,  or 
vas  deferens  being  absent.  Fusion  of  both  seminal  vesicles  has  also 
been  observed;  when  this  happens  the  single  vesicle  lies  in  the  median 
line. 

The  most  remarkable  anomaly  of  the  seminal  vesicles  is  their  union 
with  the  ureters.  It  is  explained  by  the  fact  that  the  ureter 
and  vas  deferens,  of  which  the  seminal  vesicle  is  a  diverticulum,  in  the 
beginning  of  their  development  empty  into  an  opening  in  the  uro-gen- 
ital  sinus. 

INJURIES  OF  THE  SEMINAL  VESICLES. 

Injuries  to  the  seminal  vesicles  are  inflicted  almost  exclusively  dur- 
ing operations.  Formerly  it  was  rectal  puncture  and  lateral  lithotomy 
which  brought  the  surgeon  into  conflict  with  them;  at  present,  how- 


ACUTE    INFLAMMATION    OF    THE    SEMINAL    VESICLES.  455 

ever,  these  operative  methods  have  become  antiquated.  It  is  only 
in  the  operation  for  perineal  prostatectomy  that  any  question  of  their 
injury  can  arise. 

They  occupy  such  a  well  protected  position  that  they  are  seldom 
affected  by  traumatism.  A  few  remarkable  cases,  however,  have 
been  reported.  Velpeau  saw  one  in  which  the  seminal  vesicles  were 
injured  by  a  fracture  of  the  ischium,  and  Demarquay  reports  an  in- 
stance in  which  a  rifle-bullet  perforated  the  bladder  and  seminal 
vesicle. 

ACUTE  INFLAMMATION  OF  THE  SEMINAL  VESICLES. 
(ACUTE  SPERMATOCYSTITIS.) 

Spermatocystitis  occurs  almost  exclusively  as  a  complication  of 
gonorrhoea.  The  anatomical  relation  of  the  seminal  vesicles  and  their 
ducts  with  the  urethra  sufficiently  explains  its  occurrence.  Rocher 
also  believes  in  the  existence  of  a  traumatic  form,  having  seen  one  case 
develop  as  the  result  of  a  kick  in  the  perineum.  Rapin  considers 
sexual  abuse  to  be  a  cause. 

The  symptoms  of  the  acute  form  so  closely  resemble  those  of  pros- 
tatitis that  the  two  diseases  can  frequently  not  be  distinguished  from 
one  another.  Confusion  occurs  the  more  readily  because  both  affec- 
tions usually  exist  together. 

The  patient  complains  of  a  dull  though  shooting  pain  in  the  rectum, 
which  may  increase  in  severity.  It  radiates  toward  the  perineum 
and  testicles  and  becomes  more  intense  during  micturition  and  def- 
ecation, especially  if  the  feces  are  hard. 

Coitus  is  also  painful,  although  the  desire  to  copulate  may  be  in- 
creased owing  to  frequent  erections.  Upon  ejaculation  the  sensation 
of  discomfort  is  increased  to  sharp  pain.  The  urine  contains  pus  and 
sometimes  blood.  In  a  case  as  well-marked  as  that  just  described 
diagnosis  is  not  difficult,  and  if  the  clinical  picture  is  at  all  obscure, 
palpation  through  the  rectum  will  clear  it  up.  The  probability  that 
an  inflammatory  infection  of  the  seminal  vesicles  is  present  is  increased 
if  epididymitis  or  deferenitis  can  be  discovered. 

The  course  of  acute  spermatocystitis  varies.  Frequently  complete 
resolution  takes  place;  more  rarely  the  inflammation  advances  to  sup- 
puration, the  pus  either  perforating  neighboring  organs,  or,  what  is 
more  favorable,  rupturing  into  the  urethra.  Fortunately  the  latter 
termination  is  the  more  common.     Peritonitis  resulting  from  rupture 


456  DISEASES    OF    THE    SEMINAL    VESICLES. 

of  the  abscess  has  been  very  rarely  observed.     Most  frequently  acute 
spermatocystitis  passes  into  the  chronic  stage. 

Chronic  spermatocystitis  is  much  more  difficult  to  diagnosticate, 
as  the  symptoms  are  not  so  well  pronounced  as  in  the  acute  form. 
The  history  or  existence  of  gonorrhoea  or  stricture;  simultaneous  involve- 
ment of  the  prostate  (which  is  more  easily  recognized) ;  an  uncomfort- 
able sensation  in  the  region  of  the  perineum,  between  the  bladder  and 
rectum;  increased  sensitiveness  upon  difficult  defecation;  occasional 
tenesmus;  frequent  erections  and  pollutions;  and,  finally,  the  presence 
of  pus  in  the  semen,  and  the  findings  upon  rectal  palpation; — these 
are  the  symptoms  and  signs  which  will  serve  to  strengthen  the  diag- 
nosis. 

Occasionally  colicky  pains  confined  mostly  to  the  lower  segment 
of  the  rectum  occur.  They  are  due  to  narrowing  of  the  ejaculatory 
duct  caused  by  the  inflammatory  process,  as  a  result  of  which  the 
accumulated  semen  cannot  gain  free  exit.  The  colicky  pains,  then, 
are  similar  in  origin  to  those  experienced  in  renal  and  rectal  colic, 
all  being  due  to  occlusion.  Finger  and  others  state  that  they  have 
been  able  to  feel  pear-shaped  bodies,  of  the  consistency  of  an  air- 
cushion,  on  the  posterior  surface  of  the  bladder  above  the  prostate. 
I  have  seldom,  been  able  to  do  this  without  an  anaesthetic. 

Chronic  spermatocystitis  may  be  cured.  It  may  also  persist  for  a 
great  many  years  without  causing  any  serious  difficulty  or  interfering 
in  any  way  with  the  functional  capacity  of  the  individual.  Apart 
from  the  unpleasant  sensations  just  described,  and  which  are  usually 
experienced  only  at  intervals,  neither  the  general  health  nor  the  sexual 
activity  is  disturbed.  I  have  fully  convinced  myself  that  the  semen  of 
men  affected  with  this  disease  retains  its  power  of  procreation. 

In  regard  to  the  pathological  anatomy,  hypertrophy  of  the  walls 
may  take  place,  or  atrophy  and  chondrification  may  result. 

The  therapy  of  the  acute  form  consists  in  treating  the  underlying 
causative  affection  (gonorrhoea),  enjoining  rest,  regulating  the  diet, 
increasing  the  flow  of  urine,  administering  urinary  antiseptics  such  as 
urotropin,  and  also  laxatives,  so  that  the  feces  will  not  become  hard 
and  produce  new  irritation.  If  abscess  can  be  positively  demon- 
strated it  should  be  opened  in  order  to  prevent  rupture  at  an  undesirable 
site.  Under  complete  anaesthesia  a  speculum  may  be  introduced 
into  the  rectum  and  the  vesicle  incised.  Proper  disinfection  of  the 
rectum  should  be  secured  before  the  operation  and  the  bowels  should 


TUBERCULOSIS    OF    THE    SEMINAL    VESICLES.  457 

be  confined  afterwards.  The  abscess  may  also  be  reached  by  a 
method  practised  in  operations  upon  the  prostate,  namely,  by  freeing 
the  rectum  so  that  a  space  is  made  between  it  and  the  bladder,  through 
which  the  vesicles  may  be  reached. 

Treatment  of  chronic  spermatocystitis  is  not  very  satisfactory.  It 
is  practically  the  same  as  that  of  chronic  prostatitis.  I  recommend 
massage  of  the  seminal  vesicles,  which  is  best  performed  with  Felecki's 
instrument,  at  intervals  of  two  or  three  days,  in  conjunction  with  the 
use  of  the  rectal  thermophore  on  the  other  days.  The  latter  instru- 
ment should  be  kept  in  the  rectum  for  half  an  hour  and  should  be  as 
hot  as  the  patient  can  endure.  In  addition,  mild  laxatives,  diuretics 
and  urinary  antiseptics  may  be  given,  hot  sitz-baths  employed,  the  diet 
regulated,  sexual  excesses  forbidden,  and,  if  possible,  the  causative 
gonorrhoea  or  prostatitis  cured. 

As  many  patients  become  neurasthenic  overtreatment  must  be 
guarded  against;  a  too  protracted  course  of  treatment  is  particularly 
undesirable.  Suggestive  treatment,  and  perhaps  eventually  residence 
in  a  sanitarium  where  mild  hydrotherapeutic  measures  can  be 
employed,  have  an  excellent  effect. 

[Belfield,  of  Chicago,  has  obtained  good  results  in  these  cases  by 
irrigating  and  draining  the  seminal  vesicle  through  an  opening  made 
into  the  vas  deferens.  He  exposes  the  vas  by  a  half-inch  incision 
through  the  skin  and  other  coverings  of  the  spermatic  cord,  incises 
it  by  a  transverse  or  longitudinal  cut,  and  injects  the  desired  solu- 
tion with  a  hypodermatic  syringe.  The  point  of  the  needle  used 
is  blunted,  so  that  it  may  be  inserted  well  into  the  lumen  of  the  vas 
without  producing  injury.  At  first  not  more  than  thirty  minims  of 
fluid  should  be  injected,  as  a  larger  amount  is  apt  to  produce  spermatic 
colic.  As  the  inflammation  subsides  the  quantity  of  fluid  may  be 
gradually  increased.  The  vas  deferens  may  be  stitched  to  the  skin 
with  a  piece  of  fine  silkworm  gut,  the  suture  being  passed  through 
each  cut  edge.  By  this  procedure  the  opening  is  maintained  and 
treatment  can  be  applied  daily  if  desired.  The  operation  is  done 
under  local  anaesthesia.  A  solution  of  one  of  the  organic  silver  salts 
is  generally  employed  in  gonorrhceal  infection.] 

TUBERCULOSIS  OF  THE  SEMINAL  VESICLES. 

This  is  a  more  common  affection  than  it  was  formerly  thought  to  be. 
It  almost  always  occurs  in  association  with  tuberculosis  of  some  other 


458  DISEASES    OF    THE    SEMINAL    VESICLES. 

portion  of  the  genito- urinary  organs.  It  is  generally  combined  with 
tuberculosis  of  the  testicle,  epididymis,  vas  deferens,  prostate,  bladder, 
or  kidney,  or  occurs  simultaneously  with  tuberculous  affections  of 
other  organs,  especially  the  lungs.  Primary  tuberculosis  of  the 
seminal  vesicles  is  very  rare,  or,  more  correctly  speaking,  it  is  very 
rarely  diagnosticated;  many  cases  of  tuberculosis  of  the  prostate  or 
epididymis  may  have  been  preceded  by  a  tuberculosis  of  the  seminal 
vesicle,  the  existence  of  which  was  unknown  owing  to  the  difficulty 
with  which  diagnosis  can  be  made. 

Children  are  very  seldom  affected,  the  disease  occurring  during  the 
period  of  active  sexual  life.  Trauma  and  gonorrhoea  constitute 
the  predisposing  causes.  The  frequent  congestion  of  the  generative 
organs  induced  by  sexual  excesses  may  also  supply  the  cause  for  the 
development  of  the  disease,  if  the  individual  be  predisposed  to  tuber- 
culosis. 

In  regard  to  the  morbid  changes  which  occur,  it  is  found  that  the 
mucous  membrane  is  first  covered  with  tubercles,  which  gradually 
penetrate  into  the  deeper  structures,  coalesce,  and  thereby  become  in- 
creased in  size.  As  a  result  of  the  simultaneous  inflammation  the  walls 
become  infiltrated  and  thickened,  the  tubercles  undergo  caseous 
changes,  and  ulcerations  develop  which  may  either  cause  rupture 
into  various  surrounding  structures  or  result  in  cicatricial  contraction 
of  the  entire  organ  together  with  its  excretory  ducts. 

Diagnosis  is  difficult.  The  patient  may  be  entirely  free  from 
subjective  symptoms.  There  may  be  merely  a  sensation  of  pressure 
around  the  anus  or  a  feeling  of  heaviness  in  the  perineum.  At  first 
sexual  desire  is  increased,  but  with  the  destruction  of  the  vesicles 
and  the  onset  of  constitutional  disturbances  depending  upon  the 
involvement  of  other  organs  it  becomes  diminished,  and  the  power  of 
copulation  may  be  lost.  If  the  vesicles  can  be  palpated  through  the 
rectum,  isolated,  small,  hard  nodules  may  be  felt  above  the  prostate, 
similar  to  those  which  are  detected  in  tuberculosis  of  the  latter  organ. 

Symptoms  depending  upon  tuberculosis  of  neighboring  organs 
gradually  come  to  the  fore.  If  the  prostate  and  ejaculatory  ducts  are 
involved,  a  yellowish- white  discharge  takes  place  from  the  urethra; 
this  is  of  great  diagnostic  importance,  for  if  such  a  secretion  appears 
at  the  external  urethral  orifice  of  a  man  in  whom  gonorrhoea  can  be 
excluded  and  no  other  cause  be  determined,  the  suspicion  that  it  is 
due  to  tuberculosis  of  the  seminal  vesicles  will  be  well  founded. 


CYSTS   AND   HYDROCELE    OF   THE    SEMINAL   VESICLES.  459 

As  the  morbid  process  becomes  further  developed  fistulse  may  be 
formed;  they  may  open  into  the  rectum  or  perineum,  or  into  the  large 
veins  of  the  pudic  plexus,  the  latter  occurrence  being  one  which  has 
resulted  in  death. 

Diagnosis  depends  essentially  on  the  findings  upon  palpation  and 
the  discovery  of  other  tuberculous  lesions. 

In  regard  to  treatment,  results  are  to  be  expected  only  from  surgical 
intervention,  that  is,  from  total  extirpation  of  the  seminal  vesicles. 
It  is  not  known  whether  tuberculosis  of  the  seminal  vesicles  ever 
undergoes  spontaneous  cure;  in  view  of  the  fact  that  localized  tuberculous 
lesions  of  other  organs  become  healed,  it  may  be  reasoned  by  analogy 
that  the  same  thing  may  take  place  in  these  organs. 

In  consideration  of  this  assumption  the  question  as  to  whether  a 
tuberculous  seminal  vesicle  should  be  removed  must  be  decided  by  the 
circumstances  of  the  individual  case.  In  general  the  principle  should 
be  adhered  to  that  a  tuberculous  focus  ought  to  be  destroyed  whenever 
it  is  possible  to  destroy  it  without  greatly  endangering  the  patient,  pro- 
vided, of  course,  that  its  destruction  offers  a  prospect  of  protecting  him 
from  a  dissemination  of  the  disease.  This  is  often  the  case  in  tuber- 
culosis confined  to  the  genital  tract.  Tuberculosis  affecting  the  semi- 
nal vesicles  alone,  or  associated  with  tuberculosis  of  the  testicles  or  pros- 
tate, is  therefore  operable,  whereas  a  simultaneous  tuberculosis  of  the 
lungs,  kidneys,  or  bladder  renders  it  inoperable. 

The  seminal  vesicles  may  be  removed  either  through  the  prerectal 
incision  of  Dittel  and  Zuckerkandl  or  by  the  method  of  Fritz  Konig, 
or,  as  Young  has  shown,  they  may  be  freed  from  the  posterior  surface 
of  the  bladder  through  a  suprapubic  incision.  In  the  light  of  our 
present  experience  the  perineal  operations  are  to  be  considered  the 
less  formidable. 

CYSTS  AND  HYDROCELE  OF  THE  SEMINAL  VESICLES. 

The  case  of  hydrocele  of  the  seminal  vesicles  which  is  recorded  in 
literature  was  cured  by  two  tappings.  If  for  any  reason  dilatation  of 
the  seminal  vesicles  and  consequent  stagnation  of  their  secretion 
occurs,  they  become  converted  into  cyst-like  bodies.  This  condition 
may  be  caused  by  occlusion  or  narrowing  of  the  ejaculatory  duct, 
resulting  from  inflammation,  or  it  may  be  due  to  mechanical  interference 
with  the  outflow  of  semen  depending  upon  hypertrophy  of  the  prostate. 

It  is  to  be  separated  from  true  cysts  such  as  Englisch  has  described 


460  DISEASES    OF    THE    SEMINAL    VESICLES. 

in  his  work  on  "Cysts  on  the  Posterior  Wall  0}  the  Bladder  in  Man." 
A  case  has  been  reported  by  Smith  in  which  a  cyst  of  the  seminal 
vesicle  holding  five  liters  [quarts]  produced  retention  of  urine. 

Small  unilocular  and  multilocular  cysts  develop  as  the  result  of 
isolation  and  occlusion  of  one  or  more  alveoli.  They  are  connected 
to  the  seminal  vesicle  only  by  a  peduncle  (Maisonneuve,  Englisch). 

CONCRETIONS  OF  THE  SEMINAL  VESICLES. 

A  distinction  is  made  between  concretions  and  true  calculi. 
The  first  are  small  and  produce  no  symptoms,  so  that  they  are  not  diag- 
nosticated during  life.  Some  of  them  correspond  to  the  bodies  formerly 
described  by  Trousseau  and  L'Allemand,  consisting  of  round-cells 
and  polyhedral  cuboid  epithelium  which  become  infiltrated  with 
inorganic  salts.  They  are  about  a  millimeter  in  length.  According 
to  Meckel,  they  are  cadaveric  products,  although  Fiirbringer  believes 
that  they  are  formed  during  life.  Other  concretions  are  composed 
of  mucus,  spermatozoa,  and  inorganic  matter.  Robin  has  described 
this  variety  under  the  name  of  sympexions.  They  are  insoluble  in 
acetic  acid.  Their  occurrence  is  not  very  rare,  large  numbers  com- 
monly being  found. 

Seminal  calculi  are  different,  being  composed  of  90%  of  phosphate 
and  carbonate  of  lime  and  10%  of  organic  matter  in  which  sperma- 
tozoa are  frequently  found.  They  grow  as  large  as  a  cherry-stone, 
so  that  they  may  completely  occlude  the  ejaculatory  duct.  Their 
number  may  also  be  considerable.  It  is  supposed  that  their  formation 
is  due  to  stagnation  of  the  secretion  in  the  seminal  vesicles.  Stagnation 
occurs  especially  in  advanced  age,  though  it  may  also  take  place  at  an 
early  period  of  life  when  inflammatory  processes  have  narrowed  the 
caliber  of  the  ejaculatory  duct  so  that  there  is  an  impediment  to  the 
outflow  of  semen. 

If  one  or  more  calculi  completely  occlude  the  ejaculatory  duct,  severe 
spasmodic  pain  is  experienced  when  orgasm  occurs,  to  which  the  name 
colique  spermatique  has  been  given  by  the  French.  The  semen  may 
be  completely  retained,  so  that  ejaculation  fails  to  take  place,  or  it 
may  flow  out  slowly  in  small  quantities.  It  is  not  positively  known 
whether  complete  absence  of  ejaculation  in  cases  in  which  one  ejac- 
ulatory duct  is  occluded  is  due  to  reflex  contractions  of  the  other,  or 
whether  the  congestive  swelling  produced  by  the  stone  causes  simulta- 
neous occlusion  of  the  other  duct. 


TUMORS    OF    THE    SEMINAL    VESICLES.  46 1 

Seminal  calculi  not  infrequently  give  rise  to  pain  upon  micturition 
and  defecation.  In  such  a  case  where  there  is  suspicion  of  seminal 
calculi  an  attempt  should  be  made  to  palpate  the  seminal  vesicles. 
Occasionally  a  stone  can  be  felt,  especially  if  a  metal  sound  is  introduced 
into  the  bladder  and  used  as  a  guide  in  palpating  through  the  rectum. 

The  pain  is  to  be  controlled  by  hot  sitz-baths,  and  narcotics  if  neces- 
sary. An  attempt  may  be  made  to  crush  the  calculi  through  the 
rectum  by  pressing  it  against  a  sound  introduced  into  the  bladder. 

TUMORS  OF  THE   SEMINAL  VESICLES. 

Tumors  are  rare  and  are  not  often  diagnosticated  when  they  do 
occur.  Zahn  has  reported  a  case  of  sarcoma  which  was  not  diagnos- 
ticated during  life.  The  seminal  vesicle  was  the  primary  seat  of  the 
disease  and  from  it  metastases  to  the  lung,  heart,  and  kidney  had 
taken  place. 

Carcinoma  of  the  seminal  vesicles,  which  is  somewhat  more 
common,  may  be  either  primary,  occur  as  a  metastasis  from  a  remote 
organ,  or  grow  into  the  seminal  vesicle  from  a  neighboring  structure. 
Usually  it  is  found  in  association  with  carcinoma  of  the  rectum,  bladder, 
or  prostate,  and  more  rarely  the  testicle. 

Owing  to  the  inaccessibility  of  the  seminal  vesicles  it  will  be  readily 
understood  that  carcinoma  affecting  these  organs  is  not  easily  diag- 
nosticated. As  a  rule,  the  diagnosis  is  first  made  when  severe  disturbance 
of  micturition  leads  to  the  making  of  a  thorough  examination.  Fre- 
quent urination,  lessened  capacity  of  the  bladder  owing  to  infiltration 
of  its  walls,  and  even  complete  retention  of  urine  have  been  observed. 

I  once  had  occasion  to  observe  a  case  in  which  a  hard  nodular  tumor 
was  distinctly  palpable  above  the  prostate,  from  which  it  was  separated 
by  a  furrow;  this  tumor  destroyed  the  seminal  vesicle  and  broke  through 
into  the  rectum  and  bladder.  Diagnosis  was  first  made  when  fibers 
and  fecal  elements  were  discovered  in  the  urine.  Because  of  the 
lateness  with  which  diagnosis  is  made,  it  usually  being  at  a  time  when 
metastases  have  occurred,  there  is  not  much  to  be  expected  from  radi- 
cal treatment,  so  that  we  have  to  confine  ourselves  to  a  purely  sympto- 
matic therapy. 


462  DISEASES    OF   THE    KIDNEYS. 


DISEASES  OF  THE  KIDNEYS. 

[ANATOMY  AND  PHYSIOLOGY.] 

The  kidneys  are  two  bean-shaped  glandular  organs  deeply  placed 
behind  the  posterior  parietal  peritoneum,  one  lying  on  either  side  of 
the  spinal  column,  approximately  on  a  level  with  the  last  dorsal  and 
first  two  lumbar  vertebrae.  Their  position  with  reference  to  the 
vertebras,  however,  is  variable.  Thus  one  or  both  kidneys  may 
extend  up  as  high  as  the  summit  of  the  eleventh  dorsal  vertebra  and 
as  low  down  as  the  fourth  lumbar.  The  latter  level  is  rare,  although 
it  is  not  unusual  to  find  a  kidney,  especially  the  right  one,  extending 
as  low  as  the  third  lumbar  vertebra. 

The  long  axis  of  each  kidney  is  directed  downwards,  outwards, 
and  somewhat  forwards,  so  that  there  is  a  greater  space  between 
their  lower  than  between  their  upper  extremities. 

Each  kidney  has  an  anterior  and  a  posterior  surface,  a  superior  and 
an  inferior  extremity,  and  an  internal  and  an  external  border. 

The  anterior  surface  is  convex,  directed  slightly  outwards  and 
forwards,  and  is  covered  by  peritoneum.  The  posterior  surface  is 
flattened,  and  is  intimately  surrounded  by  areolar  tissue  and  fat. 

The  extremities,  or  poles,  are  rounded,  the  superior  ones  being 
surmounted  by  the  suprarenal  glands. 

The  external  border  is  narrow  and  convex.  The  internal  border  is 
wider  and  straighter  than  the  external,  and  at  its  middle  third  presents 
a  deep  longitudinal  fissure,  known  as  the  hilum,  through  which  the 
renal  artery  and  nerves  enter  and  the  veins,  lymphatics  and  ureter 
emerge.  These  structures  form  the  surgical  pedicle  of  the  kidney, 
and  consequently  it  is  important  for  the  surgeon  to  be  familiar  with 
their  relative  position  and  the  variations  from  the  normal  which  some 
of  them  often  present.  The  relative  position  of  these  structures  is 
as  follows:  the  vein  lies  in  front,  the  ureter  behind  and  the  artery 
in  the  middle.  The  arterial  blood-supply  of  the  kidneys  may  be 
derived  from  single  or  multiple  main  arterial  trunks.  When  there 
is  but  a  single  renal  artery  it  divides  into  an  anterior  and  a  posterior 
branch,  of  which  the  anterior  is  much  the  larger.  Consequently 
the  anterior  portion  of  the  kidney  is  more  vascular  than  the  posterior. 


PLATE    XIX 


BLOOD   SUPPLY   OF  THE   KIDNEY   AND    RELATIONS   OH  THE   STRUCTURES 

SITUATED     IN    THE     HILUM    OF    THE     KIDNEY.    AS     SHOWN     BY    A 

CORROSION     PREPARATION    MADE    BY    PROF.    E.    A.    SPITZKA. 

i  COLLECTION  OF  DEPARTMENT  OF  GENERAL  ANATOMY, 

JEFFERSON    MEDICAL   COLLEGE 


ANATOMY    AND    PHYSIOLOGY.  463 

This  circumstance  may  be  utilized  to  lessen  hemorrhage  in  the 
operation  of  nephrotomy.  Thus  an  incision  made  six  millimeters 
behind  the  external  border  of  the  organ  will  open  into  its  less  vascular 
segment,  whereas  one  made  in  front  of  this  border  will  wound  the 
highly  developed  plexus  formed  by  the  subdivision  of  the  anterior 
branch  of  the  renal  artery. 

Before  the  renal  artery  passes  into  the  hilum  it  generally  gives  off 
a  branch  which  ascends  to  the  upper  pole  of  the  kidney  to  enter  the 
suprarenal  gland.  Hence  in  ligating  the  artery  in  the  operation  of 
nephrectomy,  care  should  be  taken  to  place  the  ligature  internal  to 
this  branch. 

Multiple  renal  arteries  are  present  in  a  considerable  proportion  of  all 
subjects — according  to  my  observations  in  the  dissecting  rooms  of 
Jefferson  Medical  College,  in  about  twenty-nine  per  cent.  In  some 
instances  three,  four,  or  more  vessels  are  given  off  from  the  aorta;  in 
others  a  short  thick  trunk  derived  from  the  aorta  divides  into  several 
branches.  In  either  case  it  is  noteworthy  that  only  a  portion  of  these 
vessels  enter  the  kidney  at  the  hilum.  Some  may  go  to  the  extremi- 
ties, others  penetrate  the  gland  on  its  internal  border  a  short  distance 
above  or  below  the  hilum,  and  occasionally  one  may  be  seen  passing 
to  the  external  border.  It  is  exceedingly  important  that  the  possible 
existence  of  such  anomalous  blood-vessels  be  borne  in  mind  during 
the  operation  of  nephrectomy,  and  that  any  which  are  present  be 
secured.  Patients  have  bled  to  death  from  such  vessels  which  were 
not  ligatured. 

Of  the  multiple  arteries  entering  the  hilum  some  pass  in  front  of 
the  ureter  and  some  behind  it. 

In  general  the  veins  correspond  to  the  arteries.  The  right  one  is 
much  shorter  than  the  left,  however,  so  that  in  removing  the  right 
kidney  greater  care  must  be  taken  not  to  injure  the  vena  cava. 
Frequently  two  or  three  small  veins  lie  behind  the  ureter. 

The  blood-supply  of  the  kidney  and  the  relations  of  the  structures 
in  the  hilum  are  shown  in  Plate  XIX. 

The  nerves  are  derived  from  the  renal  plexus.  They  enter  the 
hilum  upon  the  arteries.  They  communicate  with  branches  of  the 
spermatic  plexus,  a  circumstance  which  may  account  for  the  pain 
which  is  referred  to  the  testicle  in  certain  diseases  of  the  kidney. 

There  are  two  sets  of  lymphatics,  superficial  and  deep.  The 
superficial  set   consists   of  two  systems,  one  which  perforates   the 


464  DISEASES    OF    THE    KIDNEYS. 

fibrous  capsule  and  empties  into  the  perirenal  lymphatics  in  the  fatty 
capsule,  and  one  which  enters  the  substance  of  the  gland  to  unite 
with  the  deep  set.  The  channels  thus  formed  emerge  at  the  hilum  and 
empty  into  the  lumbar  glands. 

The  kidneys  are  covered  by  a  fibrous  capsule  intimately  adherent 
to  the  glandular  substance.  In  addition  thereto  they  are  invested 
by  the  renal  fascia  and  the  fatty  capsule. 

The  renal  fascia  is  a  special  portion  of  the  retro-peritoneal  con- 
nective tissue,  which  descending  from  the  lower  part  of  the  dia- 
phragm, splits  into  two  layers  above  the  superior  pole  of  the 
kidney,  one  passing  anterior  to  the  organ  and  the  other  posterior. 
The  anterior  layers  of  this  fascia  blend  with  one  another  over 
the  lumbar  vertebrae.  The  posterior  layer  on  each  side  becomes 
attached  to  the  vertebrae  along  the  inner  border  of  the  psoas  magnus 
muscle.  By  its  attachment  to  the  diaphragm  above  and  the  spine 
below,  the  renal  fascia  contributes  materially  to  the  fixation  of  the 
kidney.  This  fascia  is  stronger  on  the  left  side  than  on  the  right, 
being  fortified  by  some  fibrous  bands  remaining  from  the  union  of  the 
descending  mesocolon  with  the  parietal  peritoneum.  Thus  the  left 
kidney  is  more  intimately  connected  with  the  descending  colon  than 
the  right  kidney  is  with  the  ascending  colon,  a  circumstance  which 
perhaps  may  account  for  the  less  frequent  displacement  of  the  left 
kidney  than  of  the  right.      (Fig.  209.) 

The  fatty  capsule  is  composed  of  lobulated  adipose  tissue,  which  is 
more  abundant  around  the  posterior  surface  of  the  kidney  than  it  is 
in  front,  where  it  is  almost  always  scanty  and  sometimes  absent,  so 
that  the  true  fibrous  capsule  of  the  organ  may  be  separated  from  the 
peritoneum  only  by  the  renal  fascia.  Posteriorly  some  of  this  fat  is 
found  on  either  side  of  the  renal  fascia.  Although  the  fatty  capsule 
may  contribute  somewhat  to  the  fixation  of  the  kidney,  it  is  probably 
of  less  importance  in  this  respect  than  it  was  formerly  thought  to  be. 
The  abdominal  walls,  the  peritoneum  and  surrounding  organs  also 
afford  some  support,  but  it  is  the  renal  fascia  which  acts  most  power- 
fully in  keeping  the  kidneys  in  position. 

The  anterior  relations  of  the  two  kidneys  are  different.  The  left 
one  is  in  relation  with  the  spleen,  stomach,  pancreas,  descending  colon 
and  a  portion  of  the  small  intestine.  The  right  one  is  in  relation 
with  the  liver,  the  duodenum,  the  ascending  colon  and  also  a  portion 
of  the  small  intestine. 


ANATOMY    AND    PHYSIOLOGY. 


465 


Posteriorly  the  kidneys  are  in  relation  with  the  internal  and  external 
arcuate  ligaments  of  the  diaphragm,  the  psoas,  quadratus  lumborum 
and  transversales  muscles.  The  relation  with  the  diaphragm  brings 
the  kidneys  into  close  proximity  to  the  pleura.     The  twelfth  rib 


Pleura  phrenica. 


Diaphragma 


Capsula'adiposa  renis. 


Glandula  suprarenalis. 


Peritoneum. 


Capsula  fibrosa  renis. 


Fascia  renalis. 


Colon  descendens. 


Fascia  iliaca. 


Musculus  iliacus. 


Fig.  209. — Longitudinal  section  through  the  kidney,  suprarenal 
gland  and  renal  fascia.     (Gerota.) 


crosses  the  posterior  surface  of  the  kidney,  dividing  it  into  a  superior 
and  an  inferior  segment,  of  which  the  latter  is  the  larger.  It  is  the 
upper  segment  which  is  in  relation  with  the  pleura,  lying  behind  it 
and  being  overlapped  by  the  costo-diaphragmatic  sinus.  These 
relations  explain  why  a  perinephric  abscess  may  discharge  itself  into 
the  pleural  cavity,  and  also  why  an  empyema  is  sometimes  com- 
plicated by  a  perinephric  abscess.  In  resecting  the  twelfth  rib  in 
operations  upon  the  kidney  care  should  be  taken  not  to  open  the 
pleura.  The  experience  of  W.  J.  Mayo,  A.  J.  Ochsner  and  others, 
however,  show  that  this  accident  is  not  as  serious  as  it  was  formerly 
thought  to  be. 


466  DISEASES    OF    THE    KIDNEYS. 

Behind  the  inferior  segment  the  twelfth  dorsal,  ilio-hypogastric 
and  ilio-inguinal  nerves  pass  outwards  and  downwards.  They  are 
to  be  avoided  when  exposing  the  kidney  through  a  lumbar  incision. 

If  the  kidney  be  cut  through  from  one  border  to  the  other  its  interior 
will  be  found  to  vary  in  appearance.  Just  within  the  hilum  a  cavity, 
known  as  the  sinus,  will  be  seen.  The  larger  blood-vessels  and  the 
dilated  extremity  of  the  ureter,  the  pelvis  of  the  kidney,  as  it  is  called, 
are  contained  in  it.  The  pelvis  is  divided  into  two  or  three  tubular 
portions,  which  subdivide  into  a  number  of  branches  known  as 
calices. 

The  sinus  is  surrounded  by  the  substance  of  the  kidney,  which 
consists  of  two  parts.  The  outer  third  of  the  organ,  the  cortex,  is 
dark  in  color  and  is  made  up  of  two  distinct  structures,  the  medullary 
rays  and  the  labyrinth,  the  latter  separating  the  former  from  one 
another,  and  giving  the  cortical  substance  its  striated  appearance. 

The  medulla  is  lighter  in  color  than  the  cortex,  and  is  made  up  of  the 
Malpighian  pyramids,  separated  at  their  bases  for  a  variable  dis- 
tance by  the  columns  of  Bertini,  which  are  prolongations  of  the 
cortical  substance.  The  apices  of  these  pyramids  project  into  the 
calices  of  the  ureter,  their  openings  being  known  as  the  papillary 
ducts. 

The  cortex  of  the  kidney  contains  the  following  structures:  Within 
the  labyrinth,  the  Malpighian  corpuscles  and  the  convoluted  tubules; 
within  the  medullary  rays,  the  upper  ends  of  the  descending  and 
ascending  limbs  of  Henle's  loop  and  straight  collecting  tubules,  and 
the  arched  collecting  tubules. 

The  Malpighian  corpuscles  are  formed  by  a  little  cluster  of  arte- 
rioles, the  glomerulus,  surrounded  by  a  delicate  double  membrane, 
called  Bowman's  capsule. 

The  medulla  of  the  kidney  contains  the  lower  ends  of  the  descending 
and  ascending  limbs  and  the  loop  of  Henle,  the  straight  connecting 
tubules  and  the  papillary  ducts. 

Thus  it  is  seen  that  the  uriniferous  tubules,  beginning  in  the  Malpig- 
hian corpuscles,  have  a  very  irregular  course,  passing  from  cortex 
to  medulla,  then  back  to  the  cortex  only  to  return  to  the  medulla 
and  finally  terminate  in  the  papillary  ducts  at  the  apices  of  the 
calices. 

There  are  two  principal  theories  of  urinary  secretion,  namely, 
Ludwig's  theory  and  Bowman's  theory. 


EXAMINATION    OF    THE    KIDNEYS.  467 

Ludwig  maintained  that  the  urine  is  produced  solely  by  the 
physical  processes  of  filtration  and  diffusion.  He  believed  that  all 
the  constituents  of  the  urine — water,  inorganic  salts,  and  organic 
substances — -were  filtered  from  the  blood  in  the  glomeruli,  passing 
through  them  into  the  uriniferous  tubules. 

Bowman  assumed  that  the  water  and  inorganic  salts  are  produced 
in  the  glomeruli  by  a  process  of  secretion,  and  that  the  organic  con- 
stituents are  produced  by  a  special  secretory  power  in  the  epthelium 
lining  the  convoluted  tubules.  Without  entering  into  a  discussion 
of  the  various  experiments  which  have  been  performed  to  verify  each 
of  these  theories,  or  the  arguments  which  have  been  made  in  support 
of  each  of  them,  it  may  be  stated  that  the  weight  of  evidence  seems  to 
be  in  favor  of  Bowman's  theory.  That  it  does  not  entirely  explain 
the  process  of  urinary  secretion  will  probably  be  admitted  by  all  who 
are  familiar  with  the  literature  of  the  subject.  The  chemistry  of 
living  tissues  is  yet  obscure,  and  much  remains  to  be  demonstrated  in 
reference  to  the  vital  processes  by  which  secretions  so  complex  as  the 
urine  are  elaborated.  For  further  reference  to  this  subject  the  reader 
is  referred  to  modern  text-books  and  journals  on  physiology. 

GENERAL    CONSIDERATIONS    CONCERNING  EXAMINA- 
TION OF  THE  KIDNEYS. 

The  successful  diagnosis  and  treatment  of  diseases  of  the  kidneys 
must  rest  on  an  adequate  determination  of  their  structural  and  func- 
tional condition,  and  for  this  reason  the  most  important  points  concern- 
ing the  methods  of  examination  will  first  be  considered.  The  questions 
which  arise  in  regard  to  diagnosis  are:  (i)  What  is  the  nature  of  the 
renal  disease?  (2)  Is  it  bilateral  or  unilateral?  (3)  Which  kidney  is 
affected?  (4)  If  one  kidney  only  is  diseased,  is  the  function  of  the 
other  sufficiently  good  to  permit  an  operation,  be  it  nephrotomy  or 
nephrectomy,  upon  the  diseased  organ? 

Inspection  is  of  little  value;  it  does  not  enable  the  examiner  to 
determine  whether  a  second  kidney  is  present,  much  less  whether  it 
is  diseased. 

Percussion  is  equally  unreliable.  According  to  my  experience 
nothing  can  be  learned  from  it  regarding  the  absence  or  condition  of 
the  kidney. 

Palpation  is  of  greater  value.  It  is  practised  in  many  ways. 
Bimanual  palpation  is  employed  with  the  patient  in  the  dorsal  posi- 
32 


468  DISEASES    OF    THE    KIDNEYS. 

tion,  the  legs  being  slightly  flexed  and  a  deep  breath  being  exhaled  just 
as  the  examiner  palpates  (Turner,  Litten). 

If  the  patient  makes  his  abdomen  tense  palpation  is  of  no  use.  Under 
these  circumstances  relaxation  must  be  secured  either  by  placing  the 
patient  in  a  warm  bath  or  anaesthetizing  him  (Lennhof). 

In  conjunction  with  palpation  Guyon  employs  ballotement  renal, 
a  procedure  in  which  the  kidney  is  carried  forward  by  means  of  short 
sharp  blows  upon  the  lumbar  region,  so  that  it  can  be  more  readily  felt 
by  the  other  hand  laid  flat  upon  the  abdominal  wall.  Morris  has  the 
patient  lie  upon  the  sound  side  with  the  legs  drawn  up  and  the  body 
slightly  inclined  to  the  front.  In  this  position  the  intestines  fall  for- 
ward, the  lumbar  region  sinks  in,  and  the  kidneys  are  more  easily  felt. 
Israel's  method  of  examination  is  similar. 

Finally  there  is  the  procede  de  pouce  recommended  by  Glenard.  If 
the  right  side  is  to  be  examined  the. fingers  of  the  left  hand  are  placed 
behind,  over  the  loin,  and  the  thumb  in  front,  over  the  region  of  the 
kidney;  then  the  loin  is  pressed  upon  by  the  fingers  so  that  the  kidney 
is  pushed  forwards  where  it  can  be  felt  through  the  abdominal  wall 
by  the  other  hand. 

These  methods  are  all  serviceable.  It  is  well  to  combine  them, 
using  first  one  and  then  another. 

It  must  not  be  forgotten,  however,  that  in  many  cases  of  diseased 
and  enlarged  kidney  due  to  stone,  tumor,  tuberculosis,  or  other 
causes  nothing  can  be  felt.  It  is  the  same  with  very  fat  persons 
and  also  thin  persons  in  whom  the  kidney  lies  under  the  arch  of  the 
ribs  and  cannot  be  forced  down  by  deep  inspiration.  Moreover,  a 
kidney  of  normal  or  increased  size  may  be  palpated  and  the  examiner 
yet  be  unable  to  determine  whether  it  is  healthy  or  diseased.  Finally 
there  is  great  difficulty  in  deciding  whether  a  palpable  tumor  is  the 
kidney.  It  is  sometimes  impossible  to  differentiate  an  enlarged  gall- 
bladder from  the  right  kidney.  On  the  left  side  the  spleen  may  feel 
exactly  like  the  kidney.  So,  too,  when  the  colon  is  distended  it  often 
happens  that  little  can  be  accomplished,  for  although  this  portion  of 
the  bowel  usually  lies  over  the  kidney  and  behind  the  lower  portion  of 
the  gall-bladder,  when  it  is  distended  it  may  become  adherent  to 
neighboring  structures,  and  the  normal  relations  be  so  distorted  that 
it  may  not  lie  over  the  kidney  but  be  placed  anteriorly  to  the  gall- 
bladder. 

The  modern  method  of  examination  with  the  Roentgen  rays  has  not 


PLATE  XX. 


Kidney,  Renal  Vessels,  and  Ureters.     (Dea'ver.) 


EXAMINATION    OF    THE    KIDNEYS.  469 

added  much  to  the  diagnosis  of  renal  disease.  The  only  positive  fact 
which  has  been  learned  from  it  is,  that  certain  renal  calculi,  namely, 
those  composed  of  oxalates  and  phosphates,  and  occasionally  those 
formed  of  urates,  make  a  visible  shadow  on  the  plate  {see  the  chapter 
on  renal  calculi). 

Cystoscopy  has  afforded  great  advantages.  It  enables  us  to  see 
the  ureteral  orifices,  and  in  many  cases  to  recognize  that  disease  of  one 
kidney  is  present;  moreover,  pus  or  blood  may  be  seen  issuing  direct 
from  the  kidney.  Of  course,  in  those  cases  in  which  hematuria  or 
pyuria  is  slight,  the  method  cannot  be  relied  upon,  for  slight  turbidity 
of  the  urine  from  the  kidney  does  not  differ  materially  from  that  of 
the  fluid  present  in  the  bladder. 

This  defect  has  been  supplied  by  ureteral  catheterization.  By 
introducing  the  catheter  into  the  ureter  it  can  be  accurately  determined 
whence  the  pus  or  blood  has  its  source;  it  can  be  learned  where  the  seat 
of  the  disease  is,  and  whether  one  or  both  kidneys  are  affected.  The  exact 
nature  of  the  disease  will  then  be  determined  by  the  sum  total  of  the 
clinical  findings,  which  must  be  critically  considered. 

One  question  will  still  arise:  what  can  be  stated  concerning  the 
functional  capacity  of  the  second  kidney,  when  one  has  been  found  so 
diseased  as  to  necessitate  operation  ?  The  anatomical  diagnosis  alone 
will  not  suffice  to  decide  this  question.  For  instance,  let  us  assume  that 
we  are  dealing  with  a  tuberculous  right  kidney  and  that  the  urine  coming 
from  the  left  kidney  is  albuminous — now,  then,  is  removal  of  the  right 
kidney  contraindicated  ?  Not  at  all,  for  the  albuminuria  may  be 
merely  the  expression  of  a  remediable  toxic  disturbance  depending  upon 
a  very  restricted  amyloid  degeneration.  This  degeneration  becomes 
arrested  and  the  remainder  of  the  kidney  will  be  preserved  if  the  other 
tuberculous  kidney  is  removed.  On  the  other  hand,  clear  urine  free 
from  albumen  may  be  obtained  from  a  contracted  kidney.  .  If  the 
tuberculous  kidney  should  be  removed  in  such  a  case,  death  would 
certainly  follow  the  operation,  whereas  without  operation  the  patient 
might  live  for  years. 

In  view  of  these  circumstances  we  are  led  to  conclude  that  it  is  equally 
important  to  determine  the  functional  capacity  of  the  second  kidney. 
Will  it  alone  suffice  to  maintain  the  vital  functions  ?  Is  it  anatomically 
diseased?  Some  light  has  been  thrown  on  these  questions  by  the 
methods  of  functional  examination  introduced  by  myself  and  P.  Fr. 
Richter. 


47©  DISEASES    OF    THE    KIDNEYS. 

If  a  catheter  be  introduced  into  each  ureter  and  the  urine  from  each 
kidney  simultaneously  collected  for  a  short  time,  it  will  be  found  that 
the  quantity  of  urine  secreted  by  the  two  kidneys  is  not  always  equal, 
but  that  the  nitrogen  content  (N),  the  salt  content,  the  molecular 
concentration  (  ),  and,  if  phloridzin  (o.oi)  has  been  injected  hypo- 
dermatically,  the  quantity  of  sugar  excreted  from  the  two  sides,  will 
be  approximately  the  same.  As  the  last  two  are  the  most  certain  it 
is  sufficient  to  measure  their  value.  A  =  the  freezing  point,  which 
represents  the  totality  of  molecules  (without  reference  to  their  quality) 
contained  in  the  urine,  and  the  sugar  artificially  produced  by  the 
phloridzin  and  temporarily  excreted  by  the  kidneys. 

Phloridzin-diabetes  lasts  about  three  hours.  The  two  following 
examples  will  serve   as  illustrations. 


Normal  Case  R.  L. 

Quantity 36  cm.3  35  cm.3 

A 0.50  0.50 

Sugar 1.4%  1.4% 

N 0.213  0.206 

Or  Normal  Case 

Quantity 22  cm.3  20  cm.3 

A 0.9  1.0 

Sugar 2.0%  2.0% 


It  is  seen  that  the  figures  of  the  two  sides  are  approximately  equal. 
It  is  important  to  know  that  the  absolute  figures  do  not  express  anything. 
A  kidney  which  secretes  water  abundantly,  for  example  after  free 
drinking,  may  excrete  0.2%  of  sugar  at  one  time  and  2%  at  another 
after  exactly  the  same  amount  of  phloridzin  has  been  injected.  Only 
the  comparative  values  have  any  significance. 

If,  now,  the  function  of  one  kidney  be  disturbed,  less  nitrogen  will  be 
excreted,  fewer  molecules  will  be  elaborated  from  the  blood,  and  less 
sugar  will  be  produced  than  by  the  healthy  kidney;  therefore  the 
figures  representing  the  output  of  the  diseased  side  are  always 
lower  than  those  of  the  healthy  side.  In  cases  of  grave  disturbance 
in  which  a  considerable  portion  of  the  parenchyma  of  the  kidney  is 
destroyed,  the  freezing  point  of  the  urine  from  the  diseased  side  is 
very  low  and  sugar  is  entirely  absent.  A  few  examples  may  serve  to 
illustrate  this: 


EXAMINATION    OF    THE    KIDNEYS.  471 

1.  Right  Pyonephrosis  R.  L. 

Quantity 33.0  cm.3  25.0  cm.3 

A     0.48  1.18 

Sugar o  1.0 

N 0.322%  0.782% 

2.  Left  Renal  Tuberculosis  R.  L. 

Quantity 16  cm.3  10  cm.3 

A 1.5  °-QI 

Sugar  2.0  0.05 

N 0.63  0.385 

In  this  manner  we  obtain  a  picture  of  the  functional  power  of  the 
second  kidney,  and  are  in  a  position  to  decide,  after  carefully  weigh- 
ing all  the  circumstances  and  results  obtained  by  other  methods 
of  examination,  whether  an  operation  is  permissible. 

If  several  examinations  after  phloridzin  injections  show  that  sugar 
is  not  excreted,  and  the  undiluted  urine  is  found  to  have  a  low  freezing 
point,  the  kidney  is  functionally  incapacitated.  Removal  of  the  other 
kidney  might  be  followed  by  uraemia  and  death. 

On  the  other  hand,  the  presence  of  pus  in  the  urine  from  the  kidney 
which  is  not  to  be  operated  on  does  not  contraindicate  operation  if  it 
has  a  high  freezing  point  and  shows  a  considerable  quantity  of  sugar 
after  the  injection  of  phloridzin.  Such  a  finding  would  show  that, 
although  the  kidney  or  its  pelvis  is  diseased,  its  functional  power 
continues  to  be  good. 

It  is  obvious  that  it  may  sometimes  be  difficult  to  fix  exact  limits, 
and  that  there  is  no  absolute  protection  afforded  against  failure  of  the 
remaining  kidney.  Experience  has  already  shown  and  will  show 
further  that  deaths  from  renal  diseases  are  becoming  less  frequent. 

Our  aim  will  be  to  ascertain  to  what  extent  the  condition  of  the 
remaining  kidney  as  shown  at  autopsy  corresponds  to  the  previously 
made  diagnosis  and  prognosis. 

It  would  exceed  the  scope  of  this  book  to  enter  into  this  matter  in 
detail.  It  will  suffice  to  state  that  the  results  have  been  accepted  as 
correct  by  the  best  clinicians  and  recognized  as  the  foundation  of  a 
precise  method  of  renal  diagnosis.  The  exception  taken  to  them  by 
a  few  authors  cannot  alter  their  value  at  all,  since  our  experience  is 
derived  from  hundreds  of  cases,  while  theirs  is  based  upon  only  a  few 
exceptional  instances.  Exceptions  always  occur,  and,  as  is  well  known, 
prove  the  rule. 


472 


DISEASES    OF    THE    KIDNEYS. 


For  more  detailed  information  concerning  this  question  the  reader 
is  referred  to  the  monograph  on  Functional  Diagnosis  of  Kidney 
Diseases  by  the  author  and  P.  F.  Richter,  and  also  to  various  articles 


which  have    appeared  in  the  medical  journals  and  archives  during 
the  last  few  years. 

[Among  other  tests  devised  for  determining  the  functional  capacity  of 


EXAMINATION    OF    THE    KIDNEYS. 


473 


the  kidney  may  be  mentioned  cryoscopy  of  the  blood  and  chromo- 
cystoscopy. 

In  regard  to  the  former  it  is  probable  that  the  freezing  point  of  the 
blood  is  influenced  by  many  other  and  undeterminable  causes  aside 
from  the  action  of  the  kidney. 

Chromocystoscopy  is  of  no  value  in  showing  the  functional  capacity 
of  the  kidney.  It  is  useful,  however,  for  finding  the  orifices  of  the 
ureters  when  they  cannot  be  plainly  seen. 

Various  urine  segregators  have  been  devised  for  the  purpose  of 
obtaining  the  urine  separately  from  each  kidney  without  invading  the 
ureters.     They  are  of  two  kinds,  one  attempting  to  form  a  water-tight 


Fig.  211. — Segregator  attached  to  its  support.    (Hartmann.) 


septum  between  the  two  ureteral  orifices  which  shall  completely 
divide  the  bladder,  and  the  other  designed  to  elevate  the  posterior 
vesical  wall,  by  means  of  an  instrument  introduced  into  the  rectum, 
so  as  to  convert  it  into  a  longitudinal  fold  which  shall  separate  the 
bladder  between  the  ureteral  orifices. 

Of  the  former  kind  are  the  instruments  of  Luys  (Figs.  210,  211, 
and  212)  and  Cathelin,  of  the  latter  those  of  Neumann  and  Harris 
(Fig.  213). 

That  these  instruments  afford  the  accurate  results  offered  by  catheter- 
ization of  the  ureters  is  greatly  to  be  doubted. 

In  a  paper  read  at  the  surgical  congress  in  Berlin,  in  1905,  Prof. 
Casper  showed  that  the  mortality  of  renal  operations  has  fallen  from 


474 


DISEASES    OF    THE    KIDNEYS. 


Fig.  212. — Section  of  the  pelvis  showing  the  segregator  in  position.     (Hartmann.) 


Fig.  213. — Harris's  segregator. 


MALFORMATIONS    AND    DISPLACEMENTS    OF    THE    KIDNEYS. 


475 


26.9%  to  17.4%  in  the  last  ten  years.     He  attributes  this  decrease 
largely  to  improved  methods  of  diagnosis.] 

CONGENITAL    MALFORMATIONS    AND    DISPLACEMENTS 
OF  THE  KIDNEYS. 

Congenital  absence  of  a  kidney  is  a  rare  condition,  but  nevertheless 
it  is  one  which  has  to  be  considered  from  a  practical  point  of  view. 
Another  malformation  comparable  to  this  one  is  the  rudimentary 
kidney,  which  is  due  to  an  arrest  of  development  of  the  organ;  such  a 
kidney  is  entirely  devoid  of  functional  activity.     Absence  or  arrest 


Fig.  214. — Horseshoe  kidney  with 
broad  isthmus.     (Anterior  view.) 


Fig.  215. — Horseshoe  kidney  with  broad 
isthmus.     (Posterior  view.) 


of  development  of  one  kidney  may  be  the  only  malformation,  but 
frequently  others  are  present.  They  particularly  affect  the  genitalia, 
atrophy  of  the  testicle  and  atrophy  or  absence  of  the  seminal  vesicle 
on  the  same  side  often  being  found. 

The  occurrence  of  supernumerary  kidneys  is  not  fully  recog- 
nized by  Kiister.  He  is  of  the  opinion  that  the  condition  is  generally 
one  in  which  there  are  two  kidneys  with  multiple  pelves  and  ureters. 

If  the  condition  of  fcetal  lobulation  persists  in  later  life  the  term 
foetal  kidney  is  applied  to  it.  The  fcetal  kidney  is  characterized  by 
its  special  predisposition  to  tuberculosis. 

If  the  poles  of  both  kidneys  are  grown  together  the  organ  thus  consti- 
tuted is  known  as  horseshoe  kidney  (Figs.  214  and  215).     Most  fre- 


476 


DISEASES    OF    THE    KIDNEYS. 

A 


Fig.  216.— Displacement  of  the  left  kidney  into  the  hollow  of  the  sacrum 
A.  Aorta.  A.r.d.  Right  renal  artery  (double).  R.d.  Right  kidney  u.r.  Right 
ureter.  V.r.s.  Left  renal  vein.  A.s.r.  Right  suprarenal  artery  A.r.s.  Left 
renal  artery.     R.s.  Left  kidnev.     u.s.  Left  ureter.     (Rayer.) 


MALFORMATIONS    AND    DISPLACEMENTS    OF    THE    KIDNEYS. 


quently  it  is  the  lower  poles  which  are  grown 
together,  so  that  the  concavity  is  above.  The 
upper  poles  may  be  united,  with  the  result 
that  the  concavity  is  directed  downwards. 
The  kidney  is  usually  deeply  placed.  The 
bridge  of  union  consists  either  of  a  fibrous 
cord  or  of  kidney  tissue.  It  is  interesting 
to  note  that  in  this  condition  the  number 
of  ureters  and  renal  vessels  are  much  in- 
creased. 

Again,  both  kidneys  may  be  fused  into  a 
single  disc-like  mass  having  indentations  on 
the  border  and  lying  in  the  median  line  and 
at  a  much  lower  level  than  the  normal  organ. 
To  this  malformation  the  Germans  have 
given  the  name  Kuchenniere. 

The  term  dystopia  is  applied  to  con- 
genital displacement  of  the  organ.  Dis- 
placements occur  principally  in  association 
with  the  previously  mentioned  malforma- 
tions, but  a  normal  kidney  may  also  be 
displaced.  They  are  more  common  on  the 
left  side.  The  kidney  may  lie  upon  the 
lower  lumbar  vertebrae  (pelvic  kidney) ;  once 
I  found  it  on  the  sacrum.  The  ureters  are 
shortened  (Mullerheim).  By  establishing 
this  fact  by  means  of  ureteral  catheteriza- 
tion and  the  other  considerations  apposite 
to  the  case,  Mullerheim  was  able  in  several 
instances  to  diagnosticate  this  condition 
during  life.  The  renal  arteries  arise  from 
the  common  iliac,  the  external  iliac  and  the 
femoral  (Fig.  216). 

Displacement  of  the  pelvis  of  the  kidney 
may  occur  in  an  organ  otherwise  normally 
placed,  the  pelvis  being  at  the  anterior  sur- 
face instead  of  at  the  mesial  border. 

Very  interesting  and  of  practical  import- 
ance as  well  is  the  occurrence  of  two  renal 


Fig.  217. — Double  kidney 
and  ureter.  Kidney  has  been 
sectioned.     (Rayer.) 


478 


DISEASES    OF    THE    KIDNEYS. 


pelves.  The  ureters  issuing  from  them  may  unite  at  a  greater  or 
less  distance  below  their  origin  or  empty  into  the  bladder  separately 
(Figs.  217  and  218).  A  good  specimen  of  a  kidney  having  two  ureters 
and  affected  with  pyonephrosis  is  shown  in  Fig.  219. 

The  ureter  may  be  wanting  in  cases  in  which  the  kidney  is  absent. 
In  rudimentary  kidney  it  is  more  common  for  the  ureter  of  the  cor- 
responding side  to  end  as  a  blind  sac  extending  either  above  or  below. 


Fig.  218. — Kidney  of  a  new-born  child  with  two  ureters 
and  four  ureteral  orifices.     (Rayer.) 


It  is  not  very  unusual  for  the  ureters  to  open  in  an  abnormal  place. 
In  the  bladder  they  may  lie  either  toward  the  midline  or  lateralwards, 
or  be  displaced  posteriorly.  In  rare  cases  the  orifice  has  been  known 
to  open  into  the  posterior  urethra  near  the  caput  gallinaginis.  The 
most  unusual  condition  of  all  is  union  of  the  ureter  with  one  of  the 
seminal  vesicles,  the  vas  deferens,  or  the  ejaculatory  duct.     Finally 


MALFORMATIONS    AND    DISPLACEMENTS    OF    THE    KIDNEYS.       479 

the  ureter  may  present  variations  in  respect  to  length  and  width.     The 
last  is  the  most  important. 

There  are  points  of  predilection  for  ureteral  strictures ;  one  such  is 
the  line  of  transition  between  the  pelvis  of  the  kidney  and  the  ureter, 
a  place  where  kinking  of  the  ureter  also  frequently  occurs;  the  other 
point  is  where  the  ureter  enters  the  bladder.     In  addition  to  narrowing 


Fig.  219. — Pyonephrosis  of  a  kidney  having  two  ureters. 

of  the  ureter,  duplicature  of  the  mucous  membrane  may  take  place 
and  simulate  stricture,  and  also  give  rise  to  the  same  symptoms.  These 
duplicatures  may  have  their  seat  in  any  portion  of  the  ureter. 


480  DISEASES    OF    THE    KIDNEYS. 

CIRCULATORY  DISTURBANCES  OF  THE  KIDNEYS. 

HYPEREMIA. 

Hyperemia  of  the  kidneys  may  be  active  or  passive.  Active 
hyper aemia  occurs  as  a  result  of  increased  cardiac  action  or  because 
of  distention  of  the  renal  vessels  due  either  to  beginning  inflamma- 
tion or  to  faulty  innervation.  Therefore  it  is  merely  a  sequel  of 
other  disorders. 

Passive  hyperaemia  (engorged  kidney)  develops  as  the  result  of 
general  or  local  circulatory  obstruction.  In  valvular  disease  of  the 
heart,  myocarditis  and  endocarditis  the  propulsive  power  of  the  heart 
becomes  diminished  after  compensation  fails,  so  that  the  distention  of 
the  arteries  is  lessened,  while  that  of  the  veins  is  increased.  Any 
condition  which  increases  intra-abdominal  pressure,  thus  hindering 
the  outflow  of  blood  from  the  abdominal  organs  and  thereby  giving 
rise  to  localized  engorgement  of  the  kidneys,  may  be  considered  as 
another  cause  of  this  disease.  Among  the  causes  which  act  in  this 
way  may  be  mentioned  pregnancy,  abdominal  tumors  and  severe 
meteorism.  A  high  degree  of  local  venous  stasis  also  occurs  when- 
ever the  inferior  vena  cava  becomes  obstructed  at  any  point  above 
the  renal  veins,  or  when  the  veins  themselves  are  partly  or  entirely 
occluded.  Such  an  occurrence  may  be  due  to  thrombi  or  inflam- 
mation of  the  vessels,  or  to  tumors  which  encroach  upon  them  from 
without. 

The  anatomical  changes  which  take  place  in  the  kidney  of  passive 
hyperaemia  are  fairly  well  pronounced.  The  interstitial  veins  and 
capillaries,  which  are  swollen  and  turgid,  press  upon  the  uriniferous 
tubules  and  crowd  them  together,  while  in  Bowman's  capsule  and  the 
intertubular  spaces  small  haemorrhages  take  place;  some  of  the  glom- 
eruli are  also  much  distended.  Hyaline  casts  are  observed  in  the 
uriniferous  tubules  and  albuminous  exudate  in  Bowman's  capsule. 
If  the  stasis  continues  cyanotic  induration  of  the  kidney  results. 
The  capsule  is  thickened  and  adherent  and  strips  off  with  difficulty; 
the  epithelium  is  granular  and  fatty,  the  glomeruli  are  contracted  or 
obliterated,  and  the  interstitial  tissue  between  the  uriniferous  tubules 
and  vessels  is  increased. 

Symptoms.  Passive  congestion  of  the  kidney  when  caused  by 
general  venous  stasis  presents  the  signs  and  symptoms  of  general 
circulatory   engorgement;   namely,    cyanosis,    dyspnoea,    cardiac   and 


HEMORRHAGIC    INFARCT    OF    THE    KIDNEY.  48 1 

respiratory  disturbances,  pleural  or  mediastinal  disorder,  gastric 
catarrh,  and  enlargement  of  the  liver. 

When  the  engorgement  is  merely  local  these  phenomena  do  not 
occur.  In  either  case,  however,  the  urine  shows  characteristic  changes, 
which  are  as  follows.  The  total  amount  voided  in  twenty-four  hours 
is  less  than  normal;  the  specific  gravity  is  increased,  for  the  reason 
that  the  elimination  of  solid  elements  is  not  decreased  in  the  same 
degree  as  is  the  excretion  of  fluid;  the  reaction  is  strongly  acid  and 
turbidity  due  to  precipitation  of  urates  is  not  uncommon.  With 
increasing  stasis  albuminuria  develops  and  hyaline  casts  are  found, 
although  both  red  and  white  corpuscles  are  absent,  or  present 
only  in  very  small  numbers. 

Dropsy  supervenes,  or  if  it  were  already  present  increases  in  severity. 
During  the  period  of  transition  from  the  stage  of  engorgement  to  the 
stage  of  contraction  the  urine  becomes  cleared,  although  the  other 
symptoms  of  obstruction  remain  the  same.  From  chronic  nephritis 
passive  hyperemia  may  be  easily  differentiated  by  the  mode  of  devel- 
opment, by  the  character  of  the  urine  (absence  of  blood),  and  especially 
by  the  fact  that  passive  hyperemia  may  almost  always  be  traced  to 
heart  disease,  while  heart  disease  resulting  from  chronic  nephritis  is 
very  rare. 

The  treatment  should  be  directed,  if  possible,  to  the  removal  of  the 
underlying  cause.  An  endeavor  should  be  made  to  restore  the  broken 
cardiac  compensation,  and  for  this  purpose  the  administration  of  such 
drugs  as  digitalis,  strophanthus,  squill,  camphor  and  caffeine  is  in- 
dicated. Dropsy  is  to  be  treated  in  accordance  with  established 
principles. 

HEMORRHAGIC    INFARCT    OF    THE    KIDNEY;   THROM- 
BOSIS AND  EMBOLISM  OF  THE  RENAL  ARTERIES. 

If  the  flow  of  arterial  blood  in  the  kidney  is  checked,  a  condition 
results  to  which  the  name  of  hcemorrhagic  infarct  has  been  given. 
This  arrest  of  circulation  may  be  caused  by  spasm  of  the  vessels, 
which  narrows  or  occludes  the  main  branches  of  the  renal  artery,  or  it 
may  be  produced  by  thrombi  or  emboli  which  occlude  these  vessels. 
An  arterial  thrombosis  resulting  from  disease  of  the  vessel- wall,  such 
as  endarteritis  or  arteriosclerosis,  is  very  rare.  It  usually  results  from 
displacement  of  clots  or  inflammatory  products  from  the  left  side  of 
the  heart  or  aorta,  or  from  particles  of  tumor  which  gain  access  to 
3.3 


482  DISEASES    OF    THE    KIDNEYS. 

the  renal  blood-current  and  are  carried  to  the  vessels  of  the  glomeruli 
or  other  capillaries. 

The  infarct  forms  a  gray  or  whitish  wedge  which  is  surrounded  by 
a  haemorrhagic  area.  In  the  center  of  the  wedge  coagulation  necrosis 
develops,  the  epithelium  of  the  glomeruli  losing  its  nuclei  and  being 
destroyed.  This  results  from  the  cutting  off  of  the  blood  supply, 
which  is  due  to  occlusion  of  the  terminal  renal  vessels  by  emboli; 
the  accessory  vessels,  those  of  the  ureter  and  capsule  of  the  kidney, 
are.  not  sufficient  to  maintain  the  nutrition.  The  reddened  border 
contains  vessels  filled  with  blood.  The  infarct  finally  becomes  con- 
verted into  scar-tissue. 

The  diagnosis  of  haemorrhagic  infarct  cannot  often  be  made.  In 
order  to  make  even  a  probable  diagnosis  a  cause  for  emboli  must  be 
demonstrated  after  the  occurrence  of  sudden  pain  in  the  lumbar 
region  and  the  finding  of  albumen,  blood  and  other  morphotic  ele- 
ments in  the  urine. 

DIFFUSED  HEMATOGENOUS  NON-SUPPURATIVE  INFLAM- 
MATION OF  THE  KIDNEYS  (BRIGHT'S  DISEASE). 

As  numerous  terms  are  met  with  in  the  literature  on  Bright's  disease, 
such  as  acute,  chronic,  parenchymatous,  interstitial  and  desquamative 
nephritis,  glomerulo-nephritis,  genuine  and  secondary  contracted 
kidney,  it  is  necessary  first  of  all  to  obtain  an  adequate  conception  of 
the  conditions  to  which  the  term  Bright's  disease  itself  should  be 
applied. 

It  is  applicable  only  to  those  affections  in  which  the  primary  morbid 
process,  caused  by  irritation  of  the  altered  blood,  expresses  itself  as 
an  inflammation  involving  all  the  tissues  of  both  kidneys.  There 
is  not,  as  was  formerly  supposed,  a  purely  parenchymatous  form  in 
which  the  epithelial  elements  only  are  affected,  nor  a  strictly  interstitial 
variety  in  which  nothing  but  the  interstitial  tissue  is  the  seat  of  disease. 
In  all  forms,  in  both  the  acute  and  chronic,  but  particularly  in  the 
latter  there  is  a  diffuse  process  which  has  its  origin  in  the  parenchyma 
and  extends  to  the  interstitial  tissue,  or,  conversely,  one  which  begins 
in  the  interstitial  structure  and  later  encroaches  upon  the  epithelial 
portion  of  the  organ. 

The  most  that  can  be  said  in  regard  to  this  matter,  is  that  according 
to  the  nature  of  the  irritating  substance  producing  the  inflammation, 
the  parenchyma  will  be  affected  in  one  case  and  the  interstitial  struc- 


ACUTE    DIFFUSE    NEPHRITIS.  483 

ture  containing  the  blood-vessels  in  another.  So  likewise  from  the 
clinical  standpoint  it  can  only  be  said  that  this  or  that  tissue  is  pre- 
ponderantly affected,  and  not  that  one  is  exclusively  involved.  Weigert's 
investigations  have  abolished  this  artificial  classification  of  inflamma- 
tions of  the  kidney  and  proved  that  the  process  is  always  diffuse. 

This  does  not  mean,  however,  that  every  diffuse  process  affecting 
both  kidneys  is  a  nephritis.  Thus,  those  affections  resulting  from 
circulatory  disturbances  and  degeneration  of  the  vessels,  such  as 
passive  hyperemia  and  amyloid  degeneration,  for  example,  are  not 
to  be  considered  as  nephritis.  It  is  self-evident,  however,  that  those 
processes  which  are  localized  instead  of  diffuse  cannot  be  included 
under  the  term.  The  diseases  of  the  kidneys  in  which  there  are  foci 
of  suppuration,  and  which  constitute  the  so-called  suppurative  met- 
astatic nephritis,  rightly  belong  in  this  category. 

Accordingly,  it  is  the  object  of  this  chapter  to  describe  acute  and 
chronic  nephritis,  and  as  a  subdivision  of  the  latter  the  special  form 
known  as  contracted  kidney. 

ACUTE  DIFFUSE  NEPHRITIS. 

Etiology.  Inflammatory  processes  of  the  kidney  depend  upon  a 
morbid  condition  of  the  blood,  which  in  turn  may  be  due  to  morbific 
agents  of  various  kinds.  These  substances  are  carried  to  the  kidneys 
by  the  blood,  are  excreted,  and  in  their  progress  through  the  blood- 
vessels and  epithelium  exert  an  injurious  or  destructive  influence. 
This  toxic-hasmatogenous  origin  explains  the  circumstance  that  both 
kidneys  are  diseased  and  that  the  disease  is  diffused  throughout  the 
entire  organ. 

Unilateral  nephritis  in  the  sense  that  the  term  nephritis  is  used 
here,  and,  moreover,  as  it  is  generally  accepted,  is  a  condition  which  I 
have  never  seen,  and  did  it  exist  I  naturally  would  have  soon  encountered 
it  in  the  numerous  examinations  which  I  have  made  of  both  kidneys 
by  means  of  ureteral  catheterization. 

Furthermore  I  do  not  believe  in  inflammations  of  this  type  which 
affect  only  one  pole  of  the  kidney.  It  is  true,  however,  that  there  are 
differences  in  degree,  character  and  extent  of  the  inflammatory  processes. 
These  are  no  doubt  due  to  the  circumstance  that  healing  takes  place 
more  rapidly  in  some  parts  than  it  does  in  others,  and  that  the  involve- 
ment of  the  blood-vessels  is  not  uniform  throughout  the  kidney. 

In  regard  to  the  nature  of  these  toxic  substances,  it  must  be  admitted 


484  DISEASES   OF    THE    KIDNEYS. 

that  we  have  not  yet  succeeded  in  finding  out  enough  about  them  to 
state  that  the  development  of  all  the  forms  of  nephritis  is  explained. 
The  acute  forms  in  which  well-defined  chemical  poisons  reach  the 
body  and  are  excreted  by  the  kidneys  are  the  ones  which  are  best 
understood.  To  this  class  belong  the  cases  of  acute  poisoning  by  the 
mineral  acids,  corrosive  sublimate,  carbolic  acid,  cantharides,  potassium 
chlorate,  the  aniline  preparations  externally  employed,  extensive 
burns,  etc. 

In  like  manner  it  must  be  assumed  that  in  the  acute  infectious 
diseases  certain  toxins  are  formed  in  the  blood  which  produce  disease 
in  the  kidneys.  It  is  well  known  that  scarlet- fever,  septicaemia  and 
diphtheria  may  give  rise  to  severe  nephritis;  the  same  is  true  in  lesser 
degree  of  pneumonia  and  erysipelas  and  even  more  rarely  of  typhoid 
fever.  It  is  worthy  of  note  that  these  sequelae  may  first  manifest 
themselves  at  a  very  late  period. 

Thus  may  be  explained  the  many  cases  of  nephritis  in  which  no 
previous  malign  influence  can  be  demonstrated.  It  is  only  too 
probable  that  in  many  of  these  cases  there  has  been  an  undetected 
infection,  for  example,  a  slight  inflammation  of  the  throat,  which 
although  producing  only  trivial  local  disturbance  nevertheless  gave 
rise  to  the  formation  of  toxins  with  consequent  serious  sequelae.  There- 
fore it  need  not  be  denied  that  exposure  to  cold  and  wet,  as  was  formerly 
supposed  to  be  the  case,  may  cause  nephritis,  provided  that  we  are 
inclined  to  consider  it  as  a  factor  contributing  to  the  development 
of  inflammation  insofar  as  it  favors  increase  in  the  number  of 
microorganisms  circulating  in  the  blood  and  impels  them  to 
assume  unwonted  activity. 

Pathological  Anatomy.  The  macroscopic  appearance  of  the 
kidney  varies.  It  may  be  of  normal  size  although  it  is  more  often 
enlarged;  in  consistency  it  is  soft,  flabby  and  fragile;  the  surface  is 
smooth;  the  color  varies  from  pale  red  to  dark  red,  the  tissue  here  and 
there  showing  punctate  or  striate  areas  of  deeper  hue,  which  are  due 
to  haemorrhages ;  the  cortex  is  broadened  and  the  glomeruli  stand  out 
as  red  or  pale  granules. 

Microscopically  haemorrhages  into  the  capsule  of  the  glomeruli  and 
uriniferous  tubules  are  detected.  Cloudiness  and  swelling  of  the 
epithelium  of  the  uriniferous  tubules  and  glomeruli,  small-celled  infil- 
tration of  the  connective  tissue,  thickening  of  the  walls  of  the  vascular 
loops,  swelling  of  the  nuclei  of  the  epithelial  cells,  together  with  a 


ACUTE    DIFFUSE    NEPHRITIS.  485 

crescent-shaped  rim  of  coagulative  albumen  containing  the  detritus  of 
the  glomerular  and  capsular  epithelium,  will  also  be  observed  around 
the  vascular  loops. 

Although  these  changes  affect  the  entire  substance  of  the  kidneys, 
any  one  portion  may  be  particularly  involved.  When  the  parenchyma 
is  chiefly  affected  the  condition  is  spoken  of  as  parenchymatous  neph- 
ritis, or  to  be  more  exact,  as  tubular  nephritis  when  the  tubules  bear 
the  brunt  of  the  disease,  and  as  glomerulo-nephritis  when  the  glomeruli 
are  principally  involved;  if  the  morbid  changes  in  the  interstitial 
tissue  are  also  conspicuous,  then  the  process  is  known  as  diffuse 
nephritis. 

Symptoms.  It  is  of  the  utmost  importance  for  the  physician  to 
know  that  acute  nephritis  often  begins  without  fever.  When  a 
patient  complains  of  general  weakness,  gastro-intestinal  disturbances 
such  as  constipation,  loss  of  appetite,  nausea  and  vomiting,  suspicion 
should  be  aroused  that  renal  disease  may  be  threatening  or  already 
be  developed,  especially  if  there  is  a  history  of  a  malady  or  circum- 
stances which  are  known  to  be  capable  of  affecting  the  kidneys. 

Alterations  of  micturition,  changes  in  the  urine,  and  signs  of 
dropsy  make  an  established  nephritis  manifest.  The  urine  is  voided 
more  frequently,  is  diminished  in  quantity,  and  is  of  higher  specific 
gravity.  In  color  it  is  dark  or  red,  resembling  the  juice  of  raw  meat. 
It  contains  albumen  in  quantities  varying  from  o.i  to  i.%.  Under 
the  microscope  it  shows  red  blood-corpuscles,  mononuclear  and 
polynuclear  leucocytes,  casts  of  all  kinds — hyaline,  epithelial,  blood, 
bacterial — cylinders  composed  of  inorganic  salts,  and  renal  epithelium 
which  is  often  filled  with  fat-globules. 

The  signs  of  dropsy  usually  show  first  in  the  face,  beginning  in  the 
eyelids,  then  extending  downwards  and  finally  involving  other  parts  of 
the  body;  it  is  characterized  by  its  diverse  character  (oedema  of  the  feet 
and  legs,  oedema  of  the  scrotum,  hydrothorax  and  hydropericardium). 

Gastric  disturbances,  especially  vomiting,  are  often  the  precursors  of 
uraemia.  Inflammations  of  parenchymatous  organs  and  their  serous 
coverings  are  frequent  and  dangerous  complications  of  acute  nephritis. 
Thus  pneumonia,  pleuritis,  pericarditis,  and  peritonitis  may  occur. 

Most  cases  of  acute  nephritis  pursue  a  favorable  course  and  one 
which  is  quite  independent  of  the  underlying  causative  affection. 
In  cases  of  severe  poisoning  in  which  there  is  serious  involvement  of 
other  organs  the  prognosis  is  of  course  less  favorable.     A  fatal  termina- 


486  DISEASES    OF   THE    KIDNEYS. 

tion,  however,  is  rare.  The  duration  of  the  disease  may  extend  over 
months.  If  after  three,  or  at  the  latest  six  months,  the  symptoms 
have  not  disappeared  chronic  nephritis  almost  invariably  results.  It 
is  only  in  exceptional  cases  that  complete  cure  is  obtained  when  the 
disease  is  prolonged  beyond  this  period. 

Treatment.  Prophylaxis  is  of  the  utmost  importance.  Acute 
nephritis  can  often  be  prevented  by  avoiding  the  use  of  such  drugs  as 
are  known  to  exert  a  toxic  influence  upon  the  kidneys.  Patients  suf- 
fering from  an  acute  infectious  disease  may  also  be  saved  from  renal 
complications  by  careful  attention.  They  should  not  be  allowed 
to  get  out  of  bed  too  soon,  for  the  bodily  effort  which  they  then  are 
forced  to  make,  together  with  the  possible  exposure  to  cold,  are  injurious 
factors  in  their  cases.  Free  elimination  of  toxins  should  be  secured 
by  the  administration  of  diluents  and  the  use  of  large  quantities  of 
carbonated  waters. 

In  a  disease  which  cannot  be  cured  by  drugs  the  indicatio  causalis 
plays  a  great  role.  Rest  in  bed,  a  bland  diet,  large  quantities  of  milk, 
and  warm  baths  are  the  chief  measures  to  be  employed.  For  severe 
pain  over  the  lumbar  and  sacral  region  the  withdrawal  of  blood,  dry 
cups,  or  Priessnitz's  compresses  are  advantageous.  If  severe  bleeding 
occurs  a  styptic  such  as  ergot,  tannic  acid,  or  the  solution  of  sesqui- 
chloride  of  iron  may  be  prescribed. 

CHRONIC  NEPHRITIS. 

As  the  duration  of  acute  nephritis  is  indefinite  a  sharp  boundary- 
line  cannot  be  drawn  between  it  and  chronic  nephritis.  Therefore 
transition  forms,  subacute  and  subchronic  nephritis,  are  sometimes 
spoken  of. 

The  same  malign  influences  which  are  recognized  as  the  causes  of 
acute  nephritis,  if  long  continued,  may  lead  to  the  chronic  form.  As  in 
the  former,  so  in  the  latter,  the  noxious  substance  is  always  carried 
to  the  kidneys  by  the  blood-stream,  whether  it  be  a  drug  introduced 
from  without  or  a  toxin  generated  within  the  body.  The  most  common 
of  these  substances  are  alcohol  and  lead. 

Alcohol  may  act  directly  by  its  irritating  influence,  or  it  may  lessen 
the  resisting  power  of  the  tissues,  as  a  result  of  which  the  kidneys  can 
no  longer  perform  the  work  which  they  were  wont  to  do  without  injury; 
or  finally  alcohol  may  produce  disturbance  of  the  vessels  (arterio- 
sclerosis) and  thus  lead  to  renal  disease. 


CHRONIC    NEPHRITIS.  487 

Lead  acts  in  the  same  way.  The  form  most  frequently  met  with 
in  saturnine  intoxication  is  chronic  contracted  kidney.  In  many  cases 
both  of  these  poisons,  alcohol  and  lead,  are  responsible  for  the  develop- 
ment  of   the   disease. 

Owing  to  the  gradual  evolution  of  the  malady  it  may,  and  in  fact 
often  does  happen,  that  no  cause  can  be  determined.  In  such  cases 
it  must  be  assumed  that  many  slight  infections,  such  as  sore  throat 
for  instance,  which  are  scarcely  noticed  and  at  all  events  are  forgot- 
ten, are  the  causative  factors,  although  the  resulting  nephritis  does  not 
manifest  itself  until  a  time  when  a  cause  for  its  presence  can  no 
longer  be  found. 

Furthermore  there  are  two  diseases  of  metabolism  in  which  chronic 
nephritis  occurs  either  as  a  sequel  or  as  an  associated  phenomenon, 
namely,  gout  and  diabetes  mellitus.  So,  too,  arteriosclerosis  may 
be  recognized  as  a  frequent  cause  of  contracted  kidney. 

Besides  these  exogenous  forms  of  nephritis,  cases  of  genuine 
contracted  kidney  occur  in  comparatively  young  persons  which  we 
must  assume  with  Striimpell  to  be  due  to  congenital  constitutional 
weakness  of  the  renal  tissues,  as  the  result  of  which  the  process  of 
metabolism  cannot  be  maintained.  This  hypothesis  of  renal  weakness 
finds  support  in  the  well-known  cyclic  albuminuria,  which  occurs 
only  when  the  patient  is  up  and  about  or  after  severe  exertion  (Leube). 

Symptoms.  That  which  is  most  characteristic  of  this  form  of 
nephritis  is  the  presence  of  albumen  and  casts  in  the  urine.  It  must 
be  borne  in  mind,  however,"  that  there  are  renal  inflammations  (con- 
tracted kidney  and  amyloid  disease)  in  which  both  of  these  pathogno- 
monic elements  are  absent.  Without  albumen  and  casts  a  diagnosis 
of  nephritis  cannot,  as  a  rule,  be  made. 

Whilst  in  health  the  renal  epithelium  excretes  only  the  products  of 
destructive  metabolism,  in  nephritis  it  is  so  injured  that  it  allows 
albumen,  a  substance  useful  to  constructive  metabolism,  to  escape. 

The  excretion  of  albumen  has  also  been  considered  as  an  inflam- 
matory exudation  from  the  renal  tissues,  the  exudate  being  composed 
of  blood-serum,  and  leucocytes  which  have  migrated  through  the  walls 
of  the  blood-vessels,  and  which  become  mixed  with  the  urine. 

The  casts  are  either  exudation  products,  being  formed  by  coagula- 
tion of  the  albumen  exuded  from  the  blood-vessels,  or  they  develop 
from  the  union,  fusion  and  degeneration  of  epithelial  cells  cast  off  from 
the  uriniferous  tubules. 


488  DISEASES    OF    THE    KIDNEYS. 

In  addition  to  casts  white  and  red  blood-cells  are  also  encountered. 
The  former  migrate  from  the  blood-vessels,  the  latter  reach  the  urin- 
iferous  tubules  either  by  diapedesis  or  as  the  result  of  capillary  haem- 
orrhage. Furthermore,  renal  epithelium  is  found,  the  cells  being 
somewhat  larger  than  leucocytes,  having  large  nuclei,  and  often 
showing  fatty  granules.  Leucocytes  may  also  take  up  granules  of 
fat. 

If  the  kidneys  fail  to  excrete  the  products  of  retrograde  metabolism, 
the  retention  of  these  substances  in  the  blood  soon  makes  itself  apparent 
in  the  condition  of  the  general  health. 

The  diminution  in  the  excretive  power  of  the  kidney  cells,  in  other 
words,  the  accumulation  Of  injurious  substances  in  the  blood,  puts 
more  work  upon  the  heart,  since  it  functionates  more  actively  in  an 
endeavor  to  flush  the  kidneys  and  thereby  purify  the  blood. 

The  expression  of  this  increased  work  of  the  heart  is  a  rise  in 
arterial  blood-pressure,  increased  tension  of  pulse,  accentuation  of 
the  aortic  second  sound,  hypertrophy  of  the  left  ventricle,  and 
occasionally  of  the  right  as  well.  These  cardiac  changes  are  plainly 
shown  by  increase  in  the  area  of  cardiac  dullness  toward  the  left  (and 
also  occasionally  to  the  right)  and  abnormal  accentuation  and  resist- 
ance of  the  apex-beat.  As  long  as  this  augmentation  in  cardiac  activity 
can  prevent  the  accumulation  of  the  toxic  material  in  the  blood,  the 
term  compensated  renal  disease,  introduced  by  Strumpell,  may  be 
correctly  used. 

Among  the  general  symptoms  uraemia  may  be  first  mentioned ;  it  is 
due  to  the  accumulation  of  urinary  elements,  but  what  the  exact 
nature  of  the  poison  is  we  do  not  know.  The  intoxication  manifests 
itself  by  uremic  hemiplegia,  epileptiform  convulsions,  amaurosis, 
headache,  vomiting,  dyspnoea,  stupor,  convulsions  and  coma;  coma 
generally  supervenes  gradually,  but  it  may  develop  suddenly. 

Another  expression  of  the  toxic  substances  circulating  in  the  blood 
is  the  occurrence  of  degenerative  changes  in  the  mucous  membrane 
of  the  stomach,  intestines  and  respiratory  organs,  and  in  the  pleura, 
pericardium  and  retina.  Thus  gastritis,  enteritis,  bronchitis,  pneu- 
monia, pleuritis,  pericarditis  and  retinitis  are  not  uncommon  affec- 
tions in  those  afflicted  with  nephritis. 

It  has  not  been  positively  determined  whether  dropsy  is  a  result  of 
nephritis,  or  whether  the  same  poisons  which  produce  the  nephritis 
also  give  rise  to  changes  in  the  blood-vessels  leading  to  the  development 


PLATE    XXI 


/ 


V*1 


'vS/ 


y4      V 


LARGE   WHITE   KIDNEY,   NATURAL  SIZE.        (DRAWING    MADE   FROM   SPECIMEN    IN 
THE   MUSEUM   OF  THE  JEFFERSON   MEDICAL   COLLEGE  i 


CHRONIC    NEPHRITIS.  489 

of  dropsy.  It  is  characteristic  for  the  subjects  of  nephritis  to  have 
localized  oedema  (for  instance  that  affecting  the  face,  eyelids,  wall  of 
the  thorax  and  pleural  cavities)  in  contradistinction  to  general  dropsy 
such  as  occurs  in  cardiac  disease,  and  which  first  manifests  itself  in  the 
dependant  portions  of  the  body,  for  instance,  the  ankle-joints.  The 
disturbances  in  the  blood-vessels  may  also  give  rise  to  haemorrhages 
from  the  most  diverse  parts  of  the  body — the  nose,  the  intestines,  the 
brain. 

If  it  seems  from  what  has  already  been  stated  that  the  clinical  picture 
of  chronic  nephritis  is  so  characteristic  that  a  diagnosis  can  be  made 
without  difficulty,  the  question  will  yet  arise  as  to  whether  we  are  in 
a  position  to  decide  which  form  of  nephritis  predominates,  a  question 
which  is  of  importance  from  the  standpoint  of  prognosis  and  expectation 
of  life. 

As  the  various  causes  of  nephritis  produce  the  same  structural 
changes  it  is  not  desirable  to  classify  the  disease  according  to  its  eti- 
ology, but  rather  according  to  its  pathological  anatomy,  especially 
since  the  clinical  phenomena  are  essentially  dependent  upon  the 
anatomical  changes. 

Weigert  has  established  the  unity  of  the  different  forms  of  nephritis 
and  shown  that  the  differences  in  the  anatomical  picture,  as  in  the 
clinical,  are  merely  in  the  magnitude,  rapidity  of  development  and 
extent  of  the  morbid  process.  For  example,  if  the  poison  works  with 
great  intensity  in  equal  degree  upon  all  parts  of  the  parenchyma,  chronic 
diffuse  nephritis  develops;  if  the  malady  progresses  slowly  and  the 
destruction  of  the  parenchyma  consequently  takes  place  gradually, 
and  in  patches,  genuine  contracted  kidney  results. 

In  diffuse  nephritis,  owing  to  the  swelling  of  the  epithelium  and 
the  serous  infiltration  of  the  tissues,  the  kidney  is  enlarged  and  swollen; 
it  looks  red  when  the  blood-vessels  are  equally  distended,  pale  and 
yellow  if  the  epithelium  is  fatty,  variegated  if  infarcts  are  interspersed 
among  the  fatty  portions.  In  accordance  with  these  changes  a 
haemorrhagic,  a  large  white  fatty,  and  a  large  variegated  kidney 
are  spoken  of. 

There  is  never  a  genuine  chronic  parenchymatous  nephritis,  for 
wherever  there  is  extensive  destruction  of  renal  epithelium  there  is 
likewise  an  increase  of  interstitial  connective  tissue,  and  this  can  be 
demonstrated  early  in  the  course  of  the  malady.  If  the  process  advances 
slowly  the  kidney  remains  large  for  a  certain  length  of  time,  perhaps 


4QO  DISEASES    OF    THE    KIDNEYS. 

for  years;  the  contraction  which  the  newly  formed  connective  tissue 
produces  ensues  very  gradually,  but  results  in  the  secondary  con- 
tracted kidney  with  its  granular  surface.  This  kidney  becomes  con- 
stantly smaller  and  smaller. 

If  the  disease  comes  on  very  insidiously  the  parenchymatous  changes 
do  not  occasion  any  enlargement  of  the  organ,  but  the  genuine  con- 
tracted kidney  with  its  granular,  nodulated  surface  is  slowly  produced 


*  "•'•*•      *  1_1„ 

•           •  * » 

1   \.>v. 

1,1 '      -tfS-« 

Sf 

Fig.  220. — Chronic  parenchymatous  nephritis,  a.  Malpighian  tuft  containing 
an  unusually  large  number  of  nuclei,  b.  b.  b.  Points  at  which  there  is  slight  in- 
crease in  the  interstitial  tissue,  c.  Tubule  containing  granular,  degenerating,  epi- 
thelial cells,  which  have  coalesced,  d.  Tubule  from  which  all  the  epithelium  has 
desquamated  and  been  discharged,     e.  Blood-vessel.     (Coplin.) 

without  any  intervening  symptoms'  of  severe  disease  of  the  epithelium 
being  present.  It  may  be  either  hyperaemic,  the  red  contracted  kidney, 
or  anaemic,  the  white  contracted  kidney.  The  presently  accepted 
opinion  as  to  the  unity  of  the  pathic  process  makes  it  seem  desirable 
to  me  to  differentiate,  in  common  with  Strumpell,  the  following  forms 
of  chronic  nephritis. 

1.  The  diffuse  subchronic  and  chronic  forms,  which  generally  cause 


PLATE    XXII 


CHRONIC    INTERSTITIAL   NEPHRITIS.         (DRAWING    MADE    FROM    SPECIMEN    IN 
THE   MUSEUM   OF  THE  JEFFERSON    MEDICAL  COLLI 


CHRONIC    NEPHRITIS. 


491 


enlargement  of  the  organ;  their  subdivisions  are:  (a)  simple  diffuse 
parenchymatous  nephritis:  large  red  kidney;  (b)  parenchymatous 
nephritis  with  pronounced  fatty  degeneration  of  the  epithelium: 
large  white  kidney;  (c)  diffuse  parenchymatous  nephritis  with  haem- 
orrhages: large  variegated  kidney. 

2.  The  later  stages  of  diffuse  parenchymatous  nephritis  with 
beginning  contraction;  the  kidney  is  of  normal  size,  or  already  some- 
what smaller  than  in  health;  this  is  the  secondary  contracted  kidney. 

3.  The  genuine  contracted  kidney. 

4.  The   arteriosclerotic   contracted  kidney. 

Examination  of  the  urine  affords  the  best  means  of  distinguishing 
these  forms  clinically.   In  diffuse  chronic  parenchymatous  nephritis 


Fig.  221. — Chronic  interstitial  nephritis.  A.  Part  of  capsule.  B.  Malpighian 
body  showing  advancing  granular  and  hyaline  changes  with  marked  thickening  of 
the  capsule.  C.  C.  C.  Tubules  in  the  midst  of  newly  formed  connective  tissue;  epi- 
thelium wasted  or  absent  and  tubular  wall  notably  thickened.  The  larger  tubes  on 
the  left  and  below  are  somewhat  dilated.     (Coplin.) 


there  is  a  diminution  in  the  excretion  of  urine,  the  same  as  there  is  in  the 
acute  form;  the  quantity  may  fall  to8ooc.c.  [about  26  fluid  ounces]  or 
even  less;  the  specific  gravity  is  high,  ranging  from  1015  to  1020;  there 
is  a  considerable  quantity  of  albumen,  casts  of  all  kinds,  and  an  abun- 
dance of  whitejand  red  blood-cells  and  epithelium.     Numerous  blood- 


492  DISEASES    OF    THE    KIDNEYS. 

casts  indicate  capillary  haemorrhages;  fatty  casts  and  fatty  granular 
cells  are  signs  of  marked  fatty  degeneration  of  the  epithelium  of  the 
uriniferous  tubules. 

This  condition  of  the  Urine  is  nearly  identical  with  that  which 
obtains  in  acute  nephritis,  because  the  morbid  process,  though  differing 
in  its  duration,  is  essentially  the  same  in  character.  A  further  dif- 
ferentiation is  afforded  by  the  general  manifestations  of  the  disease, 
the  associated  conditions,  and  the  sequelae.  These  consist  in  oedema 
of  the  subcutaneous  connective  tissue,  collections  of  fluid  in  the  serous 
cavities,  uraemic  symptoms  such  as  headache  and  vomiting,  retinitis, 
and  hypertrophy  of  the  heart,  particularly  of  the  left  ventricle.  The 
duration  of  the  disease  may  extend  over  years.  The  patient  may 
succumb  at  the  end  of  a  year  or  two,  or  the  intense  phenomena  due  to 
inflammatory  and  degenerative  changes  subside,  and  secondary 
contracted  kidney  develop.  Such  a  remission  may  be  mistaken  for 
cure,  although  in  reality  the  disease  is  slowly  progressing.  Cure  may 
occur  during  the  first  months  and  perhaps  even  after  a  year.  If  the 
albumen  still  persists  at  the  expiration  of  this  period,  the  development 
of  contracted  kidney  must  surely  be  expected. 

The  clinical  picture  of  genuine  contracted  kidney  is  also  different. 
The  slowly  progressive  process  is  such  that  the  organism's  power  of 
resistance  has  time  to  establish  compensation,  and  as  a  result  of  this 
there  is  neither  marked  diminution  in  the  quantity  of  urine  nor  a 
marked  excretion  of  albumen.  On  the  contrary,  polyuria  is  usually 
present,  two  or  three  liters  of  urine  of  low  specific  gravity  (1005 -ioio), 
containing  but  little  albumen  and  few  formed  elements,  being  voided  in 
twenty-four  hours.  The  increase  in  the  quantity  of  urine  will  be  un- 
derstood if  it  is  assumed  that  arterial  pressure  is  already  raised  before 
any  considerable  injury  to  the  secretive  structures  in  the  parenchyma 
occurs. 

The  general  symptoms  and  sequelae  are  quite  in  accord  with  the 
urinary  findings,  being  very  slight,  in  fact  often  so  trivial  that  the 
disease  may  remain  unnoticed  for  years.  Headache  and  disturbances 
of  vision  not  uncommonly  lead  to  its  discovery;  later  in  its  course 
dyspnoea  due  to  cardiac  insufficiency,  weakness,  loss  of  appetite, 
emaciation  and  pallor  manifest  themselves.  (Edema  is  often  wanting 
or  occurs  late  in  the  disease.  It  is  an  expression  of  cardiac  rather  than 
renal  insufficiency.  Therefore  it  affects  the  dependant  portions  of  the 
body,  the  legs  and  ankles. 


CHRONIC    NEPHRITIS.  493 

In  case  the  circulatory  disturbances  gain  ascendancy  over  the  renal, 
the  clinical  picture  is  converted  into  one  of  uncompensated  cardiac 
disease;  the  urine  is  modified  by  the  circulatory  engorgement,  being 
small  in  quantity,  of  a  deep  color,  a  high  specific  gravity,  and  contain- 
ing much  albumen;  dyspnoea  is  also  present.  Signs  of  uraemia  may  be 
entirely  absent,  may  come  on  suddenly,  or  may  develop  gradually. 
In  the  advanced  stages  of  the  disease  complications  affecting  other 
organs  are  very  common.  Among  them  may  be  mentioned  cardiac 
disease,  hypertrophy  and  cirrhosis  of  the  liver,  arteriosclerosis,  bron- 
chitis, and  gout. 

The  arteriosclerotic  contracted  kidney  presents  the  same  clinical 
picture  as  the  genuine  contracted  kidney.  The  urine  is  pale  and  of 
low  specific  gravity,  and  polyuria  and  hypertrophy  of  the  heart  are 
present;  the  symptoms  referable  to  the  heart  and  vessels  are  more 
pronounced  than  those  produced  by  the  renal  lesions. 

Arteriosclerotic  nephritis  may  be  co- existent  with  general  arterio- 
sclerosis, the  toxins  simultaneously  causing  disease  of  the  kidneys  and 
blood-vessels;  it  may  be  a  result  of  renal  disease,  the  vessels  being 
injured  by  changes  in  the  blood  depending  upon  faulty  action  of  the 
kidneys;  and  conversely,  the  arteriosclerosis  and  obliteration  of  the 
smaller  renal  vessels  may  interfere  with  the  blood-supply  of  the  par- 
enchyma and  bring  about  necrosis.  This  condition  is  typical  in  old 
age. 

The  prognosis  of  chronic  nephritis  is  unfavorable.  The  more  diffuse 
the  morbid  process  the  sooner  will  dropsy,  uraemia  and  other  compli- 
cations ensue  and  produce  death.  The  transition  into  secondary 
contracted  kidney  is  relatively  favorable,  as  it  leads  to  an  apparent 
arrest  of  the  disease,  the  general  condition  and  functional  capacity 
of  the  body  often  being  such  that  they  leave  little  to  be  desired.  The 
anatomical  changes  may  progress  so  slowly  that  complete  destruction 
of  the  organ  does  not  take  place  for  years.  Therefore,  although  every 
contracted  kidney  shortens  life,  the  patients  may  live  from  ten  to 
twenty  years. 

The  therapeutic  measures  at  our  command  have  already  been  men- 
tioned under  acute  nephritis.  Prophylaxis  is  important.  Everything 
known  to  injure  the  kidneys,  for  instance,  certain  drugs  and  alcoholic 
beverages,  should  be  avoided.  Care  should  be  taken  to  prevent 
contraction  of  the  infectious  diseases,  and  exposure  to  cold  should 
be  guarded  against.     Furthermore  regulation  of  the  diet  is  important. 


494  DISEASES    OF    THE    KIDNEYS. 

It  should  be  unirritating,  consisting  of  milk,  vegetables,  farinaceous 
articles  and  little  meat;  highly  seasoned  food,  spices  and  alcohol  are 
to  be  interdicted.  The  patient  should  be  warmly  clad  and  obtain  as 
much  fresh  air  as  possible;  it  is  also  desirable  that  he  should  reside  in 
a  warm  climate.  The  skin  should  be  kept  active  by  two  or  three 
warm  baths  every  week  and  brisk  rubbing  with  cool  water  or  spirits. 
I  know  of  no  drugs  which  influence  the  process  favorably.  For  dropsy 
diuretics  such  as  potassium  acetate  and  diuretin,  together  with  sweating 
[the  hot  pack]  may  be  employed;  for  cardiac  insufficiency  digitalis, 
strophanthus,  and  small  doses  of  morphine;  for  chronic  uraemia 
antipyrin  and  phenacetin;  for  acute  attacks  chloral,  chloroform,  and 
venesection.  [In  cases  of  chronic  contracted  kidney  associated  with 
high  arterial  tension  and  a  greater  or  lesser  degree  of  general  arterio- 
sclerosis, I  get  good  results  from  the  use  of  nitroglycerine  in  ascending 
doses.  It  is  my  practice  to  begin  with  y^-  of  a  grain  four  times  a 
day  and  increase  gradually  as  the  patient  becomes  accustomed  to  the 
drug  and  the  latter  begins  to  lose  its  effect. 

For  the  anaemia  of  chronic  nephritis  Basham's  mixture,  in  the  dose 
of  two  or  three  drachms  three  times  a  day,  will  be  found  useful.  It 
acts  both  as  a  tonic  and  a  diuretic.  In  uraemia  the  hot  pack  and  free 
purgation  with  calomel  may  be  employed  in  addition  to  the  measures 
already  mentioned ;  and  hypodermoclysis  or  venous  infusion  of  normal 
saline  solution  may  be  used  in  conjunction  with  blood-letting.] 

THE  NEPHRITIS  OF  PREGNANCY. 

By  the  term  "nephritis  of  pregnancy"  is  understood  an  affection 
of  the  kidneys  caused  by  the  gravid  state,  but  which  is  not  generally 
recognized  as  being  inflammatory  in  character.  It  does  not  manifest 
itself  before  the  third  month  of  pregnancy,  and  its  development  is  to 
be  explained  by  assuming  that  there  is  an  accumulation  of  toxic  products 
in  the  blood ;  owing  to  the  disturbed  condition  of  the  circulation  these 
substances  are  not  properly  excreted.  Thus  there  is  a  faulty  elimina- 
tion  and  the  resulting  toxaemia  causes  the  inflammation.  The  nature 
of  these  toxins  has  not  yet  been  determined. 

The  kidney  of  pregnancy  is  pale.  There  is  extensive  fatty  degen- 
eration of  the  epithelium  and  the  convoluted  tubules.  The  clinical 
symptoms  usually  consist  in  cedema,  dropsy,  and  changes  in  the  urine 
similar  to  those  occurring  in  acute  nephritis.  The  quantity  is  dimin- 
ished, the  specific  gravity  high,  and  the  amount  of  albumen  considerable, 


AMYLOID    DEGENERATION    OF   THE    KIDNEY.  495 

although,  as  a  rule,  organized  elements  are  not  so  abundant  as  in  acute 
nephritis.  There  are  cases  in  which  casts  are  entirely  absent  through- 
out the  course  of  the  disease. 

The  disease  occasionally  has  a  rapidly  fatal  termination,  but  more 
commonly  recovery  takes  place,  the  patient  regaining  health  soon  after 
delivery.  Convulsions  occurring  before  or  during  labor  seriously 
threaten  life;  they  constitute  the  condition  known  as  eclampsia  of 
pregnant  or  parturient  women  [commonly  called  eclampsia  of  preg- 
nancy]. It  is  a  condition  concerning  the  causes  of  which  no  uni- 
formity of  opinion  has  yet  been  reached.  The  number  of  deaths  from 
eclampsia  is  fairly  large,  although  the  affection  often  terminates  in 
recovery.  It  is  exceptional  for  the  nephritis  of  pregnancy  to  lead  to 
chronic  nephritis.  The  treatment  is  the  same  as  that  recommended 
for  the  other  forms  of  nephritis.  Above  all  things,  the  prevention  of 
eclampsia  is  to  be  sought.  If  the  symptoms  are  so  menacing  that  its 
supervention  is  feared  labor  may  be  induced.  Eclampsia  itself  is  to 
be  combated  by  chloral  hydrate,  inhalations  of  chloroform,  venesec- 
tion, infusion  and  transfusion. 

AMYLOID  DEGENERATION  OF  THE  KIDNEY. 

Amyloid  degeneration  of  the  kidney  does  not  of  itself  represent  an 
inflammatory  process.  It  depends  much  more  upon  the  presence 
in  the  blood  of  some  toxic  substance  which  causes  a  disturbance  of 
the  protoplasm,  particularly  of  the  connective  tissue. 

The  causes  of  this  degeneration  are  known  to  be  long- continued 
suppuration  in  any  part  of  the  body,  bone-fistulas,  empyema,  bron- 
chiectasis, tuberculosis  of  the  lungs,  suppurative  disease  of  the  kidney 
itself,  and  tertiary  syphilis.  As  a  result  of  the  disease,  the  tissue, 
especially  the  walls  of  the  blood-vessels  in  the  glomeruli,  sustain  such 
injury  that  they  become  highly  permeable  to  albumen.  Accordingly 
there  is  a  severe  albuminuria  and  also  an  increase  in  the  quantity  of 
urine,  the  renal  capillaries  allowing  more  fluid  to  filter  through.  The 
urine  is  bright  yellow,  but  has  a  relatively  higher  specific  gravity  than 
that  of  contracted  kidney,  for  the  reason  that  it  contains  much  more 
albumen  than  the  latter.  Organized  elements  are  rare  and  generally 
are  not  met  with  at  all. 

Owing  to  the  increased  permeability  of  the  kidneys  there  is  no  reten- 
tion of  urinary  elements  in  the  blood,  so  that  symptoms  depending 
upon  such  retention,  namely,  hypertrophy  of  the  heart,   secondary 


496  DISEASES    OF    THE    KIDNEYS. 

inflammations  and  uraemia  are  absent.  The  severe  oedema  frequently 
met  with  is  to  be  explained  by  the  occurrence  of  alterations  in  the  blood- 
vessels, it  being  probable  that  the  toxins  affect  the  vessels  of  the  skin 
in  the  same  deleterious  manner  as  they  affect  deeper  structures.  It  is 
typical  for  amyloid  changes  to  occur  simultaneously  in  other  organs. 
Thus  the  liver  and  spleen  are  enlarged,  and  amyloid  degeneration  of 
the  intestines  takes  place,  giving  rise  to  diarrhoea.  The  skin  also  has 
a  striking  yellow,  waxy  appearance. 

Amyloid  tissue  gives  a  characteristic  reaction  with  Lugol's  iodine 
solution,  turning  reddish,  mahogany,  or  nut-brown  when  brought  in 
contact  with  this  fluid,  whereas  the  other  tissues  are  colored  yellow. 
It  is  colored  red  by  the  anilin  dyes,  methyl  violet,  gentian  violet  and 
methyl  green,  and  blue  by  thionin. 

Although  the  diagnosis  is  generally  not  difficult,  it  may  become  so 
when  genuine  nephritic  changes  are  superimposed  upon  the  amyloid 
degeneration,  as  the  former  affect  particularly  the  epithelium.  Under 
these  circumstances  there  is  first  a  combination  of  amyloid  kidney 
and  diffuse  nephritis  and  later  an  amyloid  contracting  kidney,  or  if 
the  nephritic  process  is  very  insidious  in  its  evolution,  a  combination 
of  genuine  contracted  kidney  and  amyloid  kidney  may  be  found. 
The  clinical  symptoms  and  the  character  of  the  urine  then  correspond 
to  a  combination  of  these  two  conditions. 

The  prognosis  of  amyloid  disease  is  not  absolutely  unfavorable. 
Of  course  those  portions  of  tissue  which  have  been  destroyed  cannot 
be  regenerated,  but  if  the  causative  factors  can  be  eliminated  the 
tissue  which  is  yet  undamaged  will  remain  healthy,  so  that  there  is 
only  a  partial  ultimate  defect.  Therefore  the  first  object  of  treatment 
is  the  removal  of  the  source  of  suppuration,  or  perhaps  the  subjuga- 
tion of  syphilis. 

FATTY  KIDNEY. 

The  term  fatty  kidney  is  applied  to  a  condition  in  which  a  collection 
of  fat  is  found  in  the  epithelium  of  the  uriniferous  tubules  without  the 
presence  of  an  associated  inflammatory  process  in  the  kidney.  The 
condition  is  one  of  fatty  degeneration  in  the  sense  that  this  term  is  used 
by  Virchow,  that  isj  the  fatty  destruction  of  renal  epithelium  is  only  a 
manifestation  of  a  general  fatty  degeneration  affecting  the  liver,  the 
heart,  the  muscles,  etc.  It  is  usually  the  result  of  an  intoxication. 
Among  the  poisons  best  known  to  produce  this  condition  are  phos- 


PYELITIS    AND    PYELONEPHRITIS.  497 

phorous,  arsenic  and  sulphuric  acid.     In  rare  instances  it  occurs  in 
pernicious  anaemia. 

PYELITIS  AND   PYELONEPHRITIS,  SUPPURATIVE   NE- 
PHRITIS, ABSCESS  OF  THE  KIDNEY. 

These  four  affections  have  much  in  common  and  are  partly  stages 
of  one  and  the  same  morbid  process.  They  all  result  from  infection 
and  are  associated  with  suppuration  in  the  kidney,  be  it  macroscopic 
or  microscopic  in  extent.  There  is,  however,  an  essential  struct- 
ural and  clinical  difference  between  them. 

Whilst  pyelitis  is  exclusively  a  disease  of  the  pelvis  of  the  kidney, 
in  pyelonephritis  the  tissues  of  the  cortex  are  also  involved.  The 
term  suppurative  nephritis  is  used  as  long  as  miliary  foci  of  suppuration 
are  present  in  the  kidney,  but  when  these  become  confluent  and  form 
a  focus  large  enough  to  be  seen  with  the  naked  eye,  the  term  kidney- 
abscess  is  applied. 

Etiology.  The  form  of  suppuration  which  develops  in  the  kidney 
and  its  pelvis  depends,  apart  from  the  circumstances  to  be  mentioned 
later,  upon  the  kind  of  infection  which  takes  place.  Microorganisms 
may  gain  access  to  the  kidney  through  the  blood-stream  or  through 
the  urinary  tract.  When  infection  occurs  in  the  former  way  it  is 
called  haematogenous,  when  in  the  latter  urogenous. 

The  type  of  haematogenous  metastatic  renal  suppuration  is  such  as 
occasionally  develops  in  pyaemia,  septicaemia,  ulcerative  endocarditis, 
pneumonia,  measles,  scarlet-fever,  small-pox,  typhoid  fever  and 
dysentery. 

The  urogenous  or  ascending  infection  almost  always  follows  a  cys- 
titis with  or  without  concomitant  retention  of  urine.  The  cystitis  of 
old  persons,  especially  prostatics,  is  almost  invariably  associated  with 
retention;  in  such  persons  long- continued  disease  very  often  leads  to 
involvement  of  the  renal  pelvis.  Young  men  suffering  from  gonor- 
rhceal  cystitis  may  also  be  attacked  by  unilateral  or  bilateral  pyelitis, 
owing  to  extension  of  the  infective  process  upwards. 

A  third  way  in  which  it  is  possible  for  infection  to  take  place  is  directly 
from  without,  as  in  wounds  of  the  kidneys. 

Finally  the  infective  microorganisms  may  wander  to  the  kidney 

from  neighboring  organs,  as  for  example,  in  inflammation  of  the  liver, 

intestines  and  psoas  muscle.     The  numerous  cases  of  infection  with 

the  bacillus  coli  communis  which  have  been  observed  must  be  considered 

34 


498  DISEASES    OF    THE    KIDNEYS. 

as  haematogenous ;  for  some  unknown  reason  the  system  becomes 
flooded  with  these  organisms  and  they  are  occasionally  deposited  in 
the  kidney  or  its  pelvis. 

In  like  manner  are  to  be  understood  those  suppurative  processes 
of  the  kidney  which  develop  as  the  result  of  infection  in  other 
parts  of  the  body,  as  for  example,  from  a  carbuncle.  In  this  in- 
stance the  microorganisms  in  the  carbuncle  are  transmitted  to  the 
kidneys  through  the  blood-stream. 

Among  the  bacteria  found  in  the  secretion  from  the  kidney  are  the 
colon  bacillus  (already  mentioned),  streptococcus,  gonococcus,  and 
proteus  vulgaris.  In  one  case  the  actinomyces  was  demonstrated  to 
be  the  exciter  of  suppuration.  The  diplococcus  pneumonias  of  Fraenkel 
and  the  typhoid  bacillus  are  also,  though  rarely,  found.  It  is  yet 
undecided  whether  the  diplococcus  ureas  of  Rovsing,  the  streptococcus 
ureas,  sarcina  alba  and  flava,  coccobacillus  ureas,  bacillus  longus 
liquefaciens,  and  bacillus  crassus  have  any  causative  relation  with 
renal  suppuration;  at  all  events  they  are  of  no  great  importance. 

It  is  evident  that  circulatory  disturbances  of  the  kidney  such  as 
occur  in  pregnancy,  and  even  in  greater  degree  in  certain  diseases 
of  the  kidney,  favor  the  development  of  infection. 

Pathological  Anatomy.  The  pelvis  of  the  kidney  shows  a  most 
variable  condition  according  to  the  character,  intensity  and  duration 
of  the  infectious  process.  It  is  slightly  or  not  at  all  dilated,  contains 
urine  which  may  be  merely  a  little  cloudy,  or  purulent,  malodorous, 
and  swarming  with  microorganisms.  The  mucous  membrane  is 
swollen,  varies  in  color  from  light  gray  to  red,  and  is  traversed  by 
dilated  vessels.  If  ecchymoses  are  present  the  condition  is  called 
hasmorrhagic  pyelitis.  The  existence  of  large  shreds  composed  of 
fibrin  and  bacteria,  which  during  life  are  sometimes  discharged  in  the 
urine,  has  led  Rovsing  to  speak, of  a  pseudomembranous  pyelitis. 
If  there  is  a  coating  similar  to  that  found  in  the  throat  in  diphtheria 
(fine  granular  masses  containing  bacteria  and  pus-corpuscles),  the 
term  croupous  or  diphtheritic  pyelitis  is  used;  if  the  coating  is  com- 
posed of  gangrenous  mucous  membrane,  the  condition  then  might  be 
called  gangrenous  pyelitis. 

If  in  addition  to  these  phenomena  obstruction  occurs,  the  pelvis  and 
calices  become  dilated.  In  consequence  of  the  pressure  to  which 
they  are  subjected  the  papillae  gradually  become  flattened,  atrophy, 
and  finally  are  destroyed.     The  pelvis  becomes  more  and  more  dilated 


PYELITIS    AND    PYELONEPHRITIS.  499 

at  the  expense  of  the  renal  tissue;  the  cortex  becomes  narrower  and 
narrower,  the  sac  wider  and  wider. 

This  form  of  extension  of  the  process  is,  as  a  rule,  peculiar  to  ascend- 
ing pyelitis,  in  which  the  ureter  is  also  involved.  The  latter  structure 
is  dilated  in  some  places  and  constricted  in  others  without  there  being 
any  material  thickening  of  the  wall  {ureteritis  interna).  The  morbid 
process  chiefly  affects  the  inner  layer  of  the  ureter.  If  superficial 
cavities  are  present,  which  represent  dilated  mucous  glands,  the  con- 
dition is  known  as  cystic  ureteritis.  In  external  ureteritis  or  periureter- 
itis, which  is  also  associated  with  constrictions,  the  outer  layers  of  the 
ureter,  the  musculature  and  its  surrounding  connective  and  fatty  tissue 
are  chiefly  affected.  The  ureter  becomes  very  much,  thickened,  is 
adherent  to  its  surrounding  structures,  and  its  lumen  may  become 
entirely  occluded. 

The  morbid  process  may  not  pursue  the  course  above  described, 
leaving  the  kidney  unimpaired  except  for  the  damage  it  sustains  in 
consequence  of  compression,  but  it  may  early  invade  the  kidney  itself, 
giving  rise  to  a  true  infectious  renal  inflammation.  We  then  have  to 
do  with  pyelonephritis. 

In  recent  cases  the  kidney  is  generally  swollen,  soft,  and  fragile. 
Upon  section  the  swelling  is  also  plainly  marked.  If  the  disease 
progresses  slowly,  radiating  gray  striations,  which  can  sometimes  be 
traced  to  the  cortex,  are  seen  when  the  kidney  is  sectioned,  and  accom- 
panying them  red  streaks  or  specks  may  be  found;  they  are  collec- 
tions of  leucocytes  derived  from  the  surrounding  inflamed  tissues  and 
in  later  stages  appear  as  minute  abscesses. 

Microscopically  the  epithelium  of  the  uriniferous  tubules,  especi- 
ally in  the  medullary  portion,  either  undergoes  proliferation  leading 
to  dilatation  of  the  tubules,  or  else  it  undergoes  retrograde  changes. 
The  cells  are  granular  and  some  are  replaced  by  fat-corpuscles. 
Areas  infiltrated  with  leucocytes  are  seen  here  and  there  in  the  con- 
nective tissue,  especially  in  the  medullary  portion,  but  also  around  the 
glomeruli.  In  the  center  of  these  areas  the  microorganisms  are  located 
and  force  their  way  out  into  neighboring  parts.  Softening  of  these 
areas  leads  to  formation  of  the  miliary  abscesses  already  mentioned. 

It  is  somewhat  different  with  descending  hematogenous  pyelitis 
and  pyelonephritis.  In  the  course  of  an  acute  infectious  disease,  or 
a  suppurative  process  in  a  remote  portion  of  the  body,  genuine  pyelitis 
may  naturally  occur  as  the  result  of  metastasis,  and  present  the  same 


500  DISEASES    OF    THE    KIDNEYS. 

structural  picture  as  urogenous  pyelitis.  This,  however,  is  exceptional. 
As  a  rule,  pelvis  and  cortex  are  simultaneously  involved,  so  that  every 
metastatic  pyelitis  is  also  a  pyelonephritis.  In  the  acute  forms,  in 
addition  to  haemorrhage  into  the  parenchyma  of  the  kidney,  changes 
in  the  epithelium  in  the  cortex  are  especially  prominent.  In  the  con- 
voluted tubules  the  epithelial  cells  are  granular  or  fatty  and  the  nuclei 
stain  poorly  or  not  at  all.  Interstitial  collections  of  leucocytes  are 
present,  particularly  in  the  region  of  the  blood-vessels.  They  contain 
microorganisms  of  all  kinds. 

If  the  process  becomes  chronic,  these  masses  of  leucocytes  are  slowly 
changed  into  circumscribed  abscesses,  which  in  contradistinction  to 
those  occurring  in  the  ascending  form,  are  located  more  in  the  cortex, 
so  that  the  surface  of  the  kidney  has  a  rough,  irregular  appearance. 
Small  foci  of  suppuration  also  occur  in  the  medullary  substance,  but 
their  arrangement  is  not  so  regular  as  that  which  characterizes  those 
in  the  cortex.  Microorganisms  are  found  in  the  blood-vessels,  espe- 
cially when  the  latter  contain  emboli.  In  the  previously  described 
ascending  form  the  microbes  are  contained  mostly  in  the  uriniferous 
tubules. 

The  longer  the  process  lasts  the  more  diverse  are  the  anatomical 
changes,  until  finally  alterations  of  the  most  different  character  are 
found  side  by  side;  thus  a  pyelitis  of  increasing  severity  may  be 
associated  with  interstitial  and  parenchymatous  nephritis  and 
simultaneous  pressure-atrophy  of  the  renal  tissue,  or  haematogenous 
infection  may  lead  to  severe  suppuration  in  the  pelvis  of  the  kidney 
and  consequent  distention  of  the  same,  in  addition  to  the  interstitial 
and  other  parenchymatous  changes  already  present. 

Symptoms  and  Course.  The  clinical  picture  is  different  in  the 
acute  and  chronic  forms.  Both,  however,  are  generally  preceded  by 
some  other  disease  of  the  kidneys  or  other  organs. 

Acute  pyelitis  usually  begins  with  chills  and  high  fever,  which 
may  reach  400  or  410  C.  [io4°-io5.8°  F.].  The  ordinary  phenomena 
accompanying  high  temperature  are  present;  the  tongue  is  dry,  thirst 
is  experienced,  and  there  is  some  hebetude.  The  urine  contains  pus, 
bacteria  and  albumen,  according  to  the  degree  of  the  nephritic  process. 

Death  sometimes  occurs  within  a  short  period;  in  other  cases  the 
fever  subsides  suddenly  or  assumes  the  remittent  type;  in  still  others 
it  gradually  becomes  normal,  and  the  acute  process  passes  into  the 
chronic. 


PYELITIS    AND    PYELONEPHRITIS.  50I 

The  renal  region  is  frequently  sensitive.  If  this  sensibility  becomes 
pronounced,  lasts  for  a  long  time,  and  if  the  chills  and  fever  recur, 
it  may  be  assumed  that  an  abscess  is  forming  in  the  kidney  or  that  one 
is  already  present. 

It  is  not  uncommon  for  the  acute  form  to  become  chronic.  More 
frequently,  however,  the  latter  form  develops  insidiously  without 
being  preceded  by  an  acute  process.  It  must  be  borne  in  mind  that 
pyelitis  and  also  pyelonephritis  may  be  entirely  unaccompanied  by 
fever.  When  of  the  secondary  form,  it  is  preceded  by  diseases  of  the 
lower  genito-urinary  tract,  such  as  gonorrhoea,  stricture,  prostatic 
affections,  tumors  of  the  bladder,  puerperal  diseases,  and  vesical 
paralyses  (tabes,  myelitis,  etc.).  The  excretion  of  pus,  tenderness 
over  the  affected  kidney,  the  development  of  a  small  swelling  in  the 
lumbar  region,  and  constitutional  disturbances  are  the  most  impor- 
tant symptoms. 

In  regard  to  the  general  condition,  it  may  be  stated  that  pyelitis 
may  exist  for  many  years  without  producing  the  slightest  constitu- 
tional disturbances.  Just  as  there  are  persons  having  chronic  cystitis 
for  years  without  impairment  of  the  general  health,  so,  too,  there  are 
others  with  pyelitis  who  suffer  no  constitutional  trouble.  Suppuration 
may  be  confined  entirely  to  the  pelvis  of  the  kidney  for  a  very  long 
period  of  time  without  the  kidney  itself  becoming  involved. 

More  frequently,  however,  nephritis  is  superimposed  upon  the  pye- 
litis. Pyelonephritis  may  also  pursue  so  slow  a  course  and  the  destruc- 
tion of  renal  tissue  which  it  leads  to  be  so  gradual  that  years  elapse 
before  the  patient  notices  any  trouble.  This,  however,  is  excep- 
tional, considerable  disturbance  usually  ensuing  within  a  short  time. 
The  patients  gradually  lose  flesh,  the  appetite  becomes  impaired, 
the  tongue  is  coated,  nausea  and  vomiting  are  present;  in  short,  they 
show  signs  of  being  seriously  ill,  presenting  a  clinical  picture  similar 
to  that  of  a  protracted  and  advanced  diffuse  haematogenous  nephritis. 

This  applies  to  unilateral  as  well  as  bilateral  ascending  pyeloneph- 
ritis. Accordingly  this  condition  of  decline  is  to  be  attributed  to  a 
poisoning  of  the  blood,  a  toxaemia,  rather  than  to  renal  insufficiency. 
The  more  frequently  attacks  of  fever  occur  during  the  malady  the 
earlier  is  the  supervention  of  the  decline. 

Tenderness  in  the  region  of  the  affected  kidney  is  a  totally  untrust- 
worthy symptom.  It  is  occasionally  present,  and  is  then  of  some 
value,  but  it  is  as  often  absent,  and  its  absence  does  not  afford  proof 


502  DISEASES    OF    THE    KIDNEYS. 

that  the  kidney  is  healthy.  Patients  often  complain  of  an  annoying 
feeling  of  pressure  in  the  region  of  the  kidneys,  which  becomes  intensi- 
fied upon  severe  exertion. 

The  same  statement  may  be  made  in  regard  to  swelling.  It  may  be 
present  or  absent.  A  pyelitis  may  exist  without  the  pelvis  of  the 
kidney  being  markedly  dilated;  a  pyelonephritis  may  be  present  in 
which  the  destruction  of  renal  tissue  leads  to  diminution  in  the  size 
of  the  kidney. 

When  there  is  a  copious  secretion  of  pus  it  is  not  unusual  for  the 
ureter  to  become  partly  or  entirely  obstructed.  This  leads  to  obstruc- 
tion in  the  pelvis  of  the  kidney;  the  kidney  itself  becomes  swollen  and 
tender.  During  this  time  the  urine  may  lose  some  of  its  turbidity 
or  even  become  perfectly  clear.  The  signs  of  retention  are  usually 
accompanied  by  fever  and  also  occasionally  by  attacks  of  typical 
renal  colic.  These  are  conditions  which  resemble  those  encountered 
in  intermittent  hydronephrosis  and  pyonephrosis,  concerning  which 
more  will  be  said  later. 

In  consequence  of  this  uncertainty  in  the  symptoms,  we  are  forced 
to  depend  upon  the  changes  in  the  urine  for  the  establishment  of  a 
diagnosis.  The  history  of  a  previous  malady  is  also  of  some  value. 
Several  peculiar  characteristics  have  been  attributed  to  pyelitic  urine. 
It  has  been  said  that  the  quantity  voided,  its  reaction,  its  albumen- 
content  and  the  kind  of  epithelium  it  contains  will  supply  sufficient 
data  for  the  establishment  of  a  diagnosis.  This  statement,  however, 
is  incorrect.  The  only  constant  and  trustworthy  characteristic 
of  pyelitic  urine  is  the  presence  of  pus. 

It  is  true  that  the  urine  of  pyelitis  and  pyelonephritis  is  usually 
acid,  but  in  the  majority  of  cases  of  cystitis  the  urine  is  also  acid.  On 
the  other  hand,  if  ammoniacal  decomposition  of  the  urine  in  the  pelvis 
of  the  kidney  takes  place,  an  alkaline  reaction  may  be  obtained  in 
pyelitis.  That  club-shaped  or  tile-shaped  epithelial  cells  placed  one 
upon  another  must  be  derived  from  the  pelvis  of  the  kidney  is  an  idea 
which  formerly  met  with  general,  acceptation,  but  at  present  it  is  gen- 
erally agreed  that  the  same  forms  may  be  derived  from  the  deeper 
strata  of  the  lower  urinary  tract;  consequently  their  presence  does  not 
constitute  a  means  of  differential  diagnosis. 

Furthermore,  as  concerns  the  albumen-content,  it  is  entirely  wanting 
in  true  pyelitis.  Only  as  much  albumen  is  found  as  is  contained  in 
the  pus  which  is  excreted.     Even  when  the  latter  is  present  in  large 


PYELITIS    AND    PYELONEPHRITIS.  503 

quantity  the  amount  of  albumen  will  scarcely  exceed  0.1%.  In  pyelo- 
nephritis the  albumen-content  is  naturally  higher,  as  it  corresponds  to 
the  amount  of  pus  secreted  and  therefore  increases  gradatim  with  the  in- 
volvement of  the  kidney.  Pyelonephritis,  therefore,  may  be  differen- 
tiated from  cystitis  by  means  of  the  albumen-content,  but  simple 
pyelitis  cannot  thus  be  distinguished. 

Casts  are  not  present  in  true  pyelitis,  nor  do  they  occur  in  pyelo- 
nephritis as  a  rule,  being  absent  just  as  they  often  are  in  contracting 
kidney.  Their  constant  presence  points  towards  pyelonephritis,  but 
their  absence  does  not  exclude  the  possibility  of  this  disease. 

The  presence  of  pus  in  the  urine  is  the  only  positive  sign.  As 
admixture  of  pus  occurs  in  other  diseases,  for  example,  in  certain 
affections  of  the  bladder  and  prostate,  the  task  of  determining  whether 
the  pus  originates  in  the  kidney  may  be  reserved  for  those  cases  in 
which  its  presence  cannot  be  traced  to  some  other  source. 

Moreover,  if  the  diagnosis  of  pyelitis  or  pyelonephritis  be  accepted, 
it  still  remains  to  be  determined  whether  the  disease  is  unilateral  or 
bilateral.  In  most  cases  careful  observation  of  the  course  of  the  dis- 
ease will  enable  one  to  make  a  differential  diagnosis,  or  at  least  to 
determine  whether  cystitis  alone  is  present,  or  whether  there  is  an  as- 
sociated pyelitis. 

For  this  purpose  the  effect  of  treatment  is  of  assistance.  All  forms 
of  cystitis  except  those  due  to  malignant  tumors  and  tuberculosis 
improve  under  proper  local  treatment.  The  subjective  symptoms 
abate  and  the  urine  becomes  clear.  If  the  amount  of  pus  fails  to 
decrease  despite  careful  treatment,  and  tuberculosis  and  malignant 
disease  of  the  bladder  can  be  excluded,  one  will  seldom  go  wrong  in 
assuming  that  the  pus  comes  from  the  kidney  or  pelvis  of  the  kidney. 

The  positive  determination  of  the  source  of  the  pus,  as  well 
as  knowledge  relative  to  which  kidney  is  affected,  is  afforded 
only  by  cystoscopy  and  catheterization  of  the  ureters.  The  ori- 
fices of  the  ureters  are  revealed  by  the  cystoscope,  and  the  turbid,  pur- 
ulent urine  can  often  be  seen  issuing  from  them.  If  the  turbidity  is  so 
slight  that  it  cannot  be  determined  whether  the  fluid  spurting  from  the 
ureters  is  cloudy  or  not,  a  ureteral  catheter  is  introduced  and  the  urine 
thus  collected.  If  pyelitis  is  not  present  the  urine  will  contain  only 
epithelium,  or  perhaps  only  a  few  red  blood-corpuscles,  their  presence 
being  due  to  diapedesis  resulting  from  hyperaemia.  Otherwise  it  con- 
tains pus-corpuscles. 


504  DISEASES    OF    THE    KIDNEYS. 

To  determine  whether  the  kidney  itself  is  affected  its  functional 
capacity  should  be  tested  (see  page  469).  In  simple  pyelitis  or  chronic 
interstitial  nephritis  each  kidney  will  give  approximately  the  same 
value  for  A  and  sugar,  whilst  in  pyelonephritis  the  diseased  kidney 
will  give  a  value  less  than  that  of  the  healthy  one. 

The  prognosis  of  suppuration  in  the  kidney  is  variable.  Simple 
pyelitis  may  exist  for  years  without  the  kidney  itself  becoming  involved 
and  without  producing  any  disturbance  whatever.  Pyelonephritis, 
as  a  rule,  gradually  leads  to  destruction  of  the  kidney,  and  therefore 
must  be  considered  as  a  serious  malady.  Pyelitis  also  not  uncommonly 
invades  the  kidney  and  its  importance  is  not  to  be  underrated.  Uni- 
lateral affections  naturally  offer  a  more  favorable  prognosis  than 
bilateral. 

Treatment.  The  treatment  of  acute  pyelitis  consists  in  the  employ- 
ment of  antiphlogistic  measures,  the  local  abstraction  of  blood,  the 
application  of  ice,  narcotics  for  the  relief  of  severe  pain,  quinine, 
salicylic  acid  and  antipyrin  for  fever,  urotropin  for  disinfection  of  the 
renal  pelvis,  and  the  use  of  moist  warm  cataplasms  in  the  subacute 
forms.  A  bland  diet  and  regular  evacuation  of  the  bowTels  are  of 
course  necessary.  The  patient  should  drink  freely;  Fachingen, 
Wildungen  and  similar  waters  are  well  suited  to  these  cases.  In  the 
majority  of  cases  these  measures  will  overcome  the  disease,  or  at  least 
allay  its  most  violent  manifestations,  so  that  it  passes  into  the  chronic 
stage. 

If  threatening  symptoms  persist,  such  as  high  fever  and  chills,  and 
if  an  exact  diagnosis  has  been  made  as  to  which  kidney  is  diseased, 
or  at  least  as  to  which  one  is  the  more  diseased,  a  brilliant  curative 
effect  can  sometimes  be  obtained  by  splitting  the  kidney.  This 
applies  to  pyelitis  as  well  as  to  pyelonephritis.  This  procedure  will 
naturally  be  of  use  only  in  the  ascending  forms,  or  in  metastatic 
suppurative  processes  in  which  the  primary  disease  with  its  localiza- 
tion in  other  organs  has  already  or  is  about  to  become  extinct. 

In  regard  to  the  treatment  of  chronic  pyelitis  and  pyelonephritis, 
the  measures  already  mentioned  for  the  acute  form  should  be  tried 
first.  These  consist  in  drinking- cures,  rest,  baths,  diet,  and  the 
administration  of  urotropin.  The  chances  of  cure  by  these  means, 
however,  are  slight. 

For  pyelitis  of  benign  nature,  or  in  other  words  one  due  to  the 
gonococcus  or  bacillus  coli  communis,  irrigation  of  the  pelvis  of  the 


HYDRONEPHROSIS.  505 

kidney  with  silver  nitrate  solution  i :  iooo  is  wonderfully  effective.  I 
have  tried  it  in  twelve  cases  (nine  due  to  the  gonococcus  and  three  to 
the  bacillus  coli  communis)  which  had  resisted  all  other  treatment 
and  have  obtained  a  perfect  cure  in  every  case.  It  is  contraindicated 
in  pyelonephritis,  and  when  tuberculosis  or  renal  calculi  affect  the 
pelvis  of  the  kidney.  If  the  tubercle  bacillus  cannot  be  found,  it  can 
be  learned  whether  the  suppuration  is  dependent  upon  tuberculosis 
by  inoculating  a  guinea-pig  with  the  secretion.  The  diagnosis  of 
pyelonephritis  can  be  accepted  when  the  functional  renal  examination 
shows  a  considerable  diminution  in  the  value  of  A  and  sugar  in  com- 
parison with  the  urine  from  the  opposite  kidney.  In  suppuration 
due  to  calculi  irrigation  of  the  renal  pelvis  has  a  transitory,  but  not 
permanent,  beneficial  effect.  The  suppuration  becomes  less  but  does 
not  cease. 

t 

In  unilateral  pyelonephritis  good  results  may  be  obtained  by  neph- 
rotomy, provided  that  the  disease  is  not  too  far  advanced.  The  kid- 
ney is  laid  open,  washed  out  with  i :  iooo  silver  nitrate  solution,  and 
the  wound  left  unclosed.  If  the  kidney  has  been  destroyed  by  multi- 
ple foci  of  suppuration,  nephrectomy  is  indicated,  provided  of  course 
that  the  functional  capacity  of  the  other  kidney  permits  it.  It  has 
not  been  positively  determined  whether  cure  can  be  obtained  in  bi- 
lateral pyelonephritis  by  operating  first  on  one  kidney  and  then  later 
on  the  other.  Before  the  question  is  decided  information  must  be  col- 
lected in  regard  to  the  degree  of  danger  incident  to  such  a  procedure. 

HYDRONEPHROSIS. 

Etiology.  Various  names  have  been  applied  to  those  affections 
of  the  kidney  in  which  fluid  accumulates  in  the  renal  pelvis  and  causes 
it  to  become  distended.  Among  these  may  be  mentioned  cystineph- 
rosis,  sacciform  kidney,  and  hydronephrosis.  I  prefer  the  term 
hydronephrosis,  which  was  first  used  by  Rayer,  and  shall  designate 
as  such  those  dilatations  of  the  pelvis  of  the  kidney  which  are  caused 
by  obstruction  to  the  outflow  of  urine. 

There  is  a  congenital  and  an  acquired  form  of  hydronephrosis.  In 
the  former  either  the  condition  itself  or  the  causes  leading  to  it  may  be 
congenital.  Generally  there  is  a  partial  obliteration  or  stenosis  of  the 
ureter;  the  points  of  predilection  are  the  outlet  of  the  ureter  from  the 
renal  pelvis,  and  that  portion  which  traverses  the  bladder. 

Reduplications  and  valves,  kinking  and  torsion,  or  abnormal  inser- 


506  DISEASES    OF   THE    KIDNEYS. 

tion  of  the  ureter  into  the  renal  pelvis  may  have  the  same  effect.  If 
the  ureter  at  its  outlet  forms  an  acute  angle  with  the  pelvis  of  the  kidney, 
its  opening  will  become  closed  much  like  a  valve  when  the  pelvis 
becomes  very  full ;  if  its  opening  is  high  instead  of  low  the  urine  will  not 
have  a  proper  outflow.  In  connection  with  the  development  of 
hydronephrosis  those  cases  in  which  there  is  a  double  renal  pelvis  and 
double  ureters  are  of  special  interest.  When  such  conditions  exist  the 
renal  pelvis  whose  ureter  opens  abnormally  in  the  bladder  and  thus 
constitutes  an  obstruction  to  the  outflow  of  urine  is  the  one  in  which 
hydronephrosis  develops.  Among  the  acquired  causes  of  hydroneph- 
rosis are  inflammatory  affections  of  the  urinary  organs  and  concre- 
tions which  interfere  with  the  outflow  of  urine.  The  first  class  is 
constituted  principally  by  ulcerative  ureteritis  leading  to  stricture- 
formation,  and  peri-  and  para-metritic  exudates  which  compress  the 
ureters;  furthermore  tumors  of  the  bladder,  uterus,  and  ovaries,  new 
growths  of  the  pelvic  bones,  enlargement  of  the  prostate,  uterine  re- 
flexes occurring  during  pregnancy  or  independently  thereof,  kinking 
and  torsion  of  the  ureter  resulting  from  displacement  of  the  kidney, 
may  all  produce  obstruction  and  thus  give  rise  to  hydronephrosis. 

Floating  kidney  particularly  predisposes  to  the  so-called  intermittent 
hydronephrosis  (Landau),  which  is  characterized  by  the  fact  that  the 
distended  renal  pelvis  is  filled  with  fluid  at  one  time  and  is  empty 
at  another.  In  consequence  of  the  descent  of  the  kidney,  the  origin  of 
the  ureter,  which  is  normally  situated  at  the  lowest  portion,  reaches 
a  higher  or  perhaps  the  highest  level.  If  no  cause  for  the  development 
of  hydronephrosis  can  be  found  at  operation  or  autopsy,  it  must  be 
assumed  that  the  cause  has  been  overlooked  or  rendered  unrecogniz- 
able by  the  manipulations  which  have  been  practised. 

Hydronephrosis  is  more  often  unilateral  than  bilateral,  and  the 
right  side  is  more  often  affected  than  the  left.  The  female  sex  is 
specially  predisposed  in  consequence  of  the  numerous  diseases  of  their 
genital  organs  which  produce  compression  of  the  ureters. 

Pathological  Anatomy.  Total  hydronephrosis,  that  is,  one  in 
which  the  entire  kidney  is  converted  into  a  sac,  so  that  no  renal  tissue 
is  left,  is  very  rare,  occurring  mostly  in  kidneys  with  double  ureters. 
If  the  obstruction  in  the  ureter  is  high  up  near  the  pelvis  of  the  kid- 
ney, the  pelvis  only  is  dilated,  whilst  the  lower  the  impediment  to  the 
outflow  of  urine,  the  greater  is  the  liability  of  the  ureter  also  becom- 
ing dilated. 


HYDRONEPHROSIS.  507 

If  the  obstruction  develops  suddenly  and  the  ureter  is  completely 
occluded,  the  renal  pelvis  will  be  only  moderately  distended,  whereas 
if  the  obstruction  develops  more  gradually,  as  is  the  case  when  a  por- 
tion of  the  lumen  of  the  ureter  remains  open,  an  enormous  sac,  which 
may  attain  the  size  of  a  man's  head,  is  formed. 

In  the  first  instance  it  is  not  unusual  for  the  functional  power  of  the 
kidney  to  be  lost,  but  when  slow  and  only  partial  obstruction  of  the 
ureter  occurs  the  kidney  still  continues  to  secrete  urine,  which  stagnates 
and  distends  its  pelvis.  When  there  is  permanent  complete  occlusion 
the  term  closed  hydronephrosis  is  used  to  designate  the  condition,  and 
when  complete  obstruction  does  not  exist,  so  that  some  of  the  urine 
can  escape,  we  employ  the  term  open  hydronephrosis. 

It  is  upon  these  conditions  that  the  reaction  upon  the  kidney  itself 
depends.  Closed  hydronephrosis  rapidly  leads  to  flattening  of  the 
papillae  and  causes  pressure  atrophy  of  the  medullary  and  cortical 
substance,  so  that  finally  nothing  but  dilated  calices  remain,  forming, 
together  with  the  pelvis,  a  large  thin- walled  sac  in  which  a  few  ridges, 
the  remnants  of  the  calices,  may  be  seen.  Such  complete  destruction, 
however,  is  exceptional.  As  a  rule,  normal  renal  tissue  or  tissue 
showing  interstitial  changes  will  be  found;  in  the  latter  case  the 
epithelium  of  the  uriniferous  tubules  will  show  degenerative  changes 
due  to  pressure. 

The  contents  of  the  sac  is  watery  fluid  having  a  uriniferous  odor; 
in  recent  accumulations,  or  in  the  intermittent  form  of  hydroneph- 
rosis, it  possesses  the  properties  of  urine,  whereas  in  older  cases  w  th 
complete  occlusion  of  the  sac  only  a  little  urea  is  found. 

Symptoms  and  Course.  Small  hydronephrotic  sacs  may  not  cause 
any  symptoms.  Larger  ones  are  characterized  by  a  swelling  which 
may  assume  enormous  dimensions.  This  swelling  may  be  oblong  or 
round,  its  surface  is  smooth,  and  occasionally  a  soft  portion  (the  sac) 
and  a  hard  portion  (indurated  kidney  tissue)  can  be  distinguished  upon 
palpation.  It  shows  more  respiratory  displacement  on  the  right  side 
than  on  the  left.  Fluctuation  may  or  may  not  be  detected.  Percussion 
supplies  information  concerning  many  of  the  conditions  present. 
There  is  generally  a  zone  of  tympanitic  resonance  between  the  area 
of  liver  dullness  and  that  over  the  hydronephrotic  sac.  By  inflating 
the  colon  it  will  often  be  found  that  the  kidney  lies  behind  this 
portion  of  the  bowel,  although  this  sign  often  fails  owing  to  the  fact 
that  the  intestine  is  pushed  to  one  side  by  the  tumor. 


508  DISEASES    OF    THE    KIDNEYS. 

Another  symptom  is  a  feeling  of  pressure  over  the  affected  side. 
This  may,  however,  be  entirely  wanting,  but  as  a  rule  it  is  present,  and 
may  occasionally  amount  to  severe  pain,  or  even  be  increased  to 
violent  colic.  Intermittent  hydronephrosis,  during  the  period  of 
complete  retention  of  urine,  sometimes  produces  symptoms  identical 
with   those    of   nephrolithiasis. 

The  urine  may  be  perfectly  normal.  Occasionally  a  remarkable 
variation  in  its  quantity  and  properties  is  observed,  which  gives  rise 
to  the  suspicion  that  there  is  a  variation  in  the  quantity  contained 
in  the  pelvis  of  the  kidney. 

Even  when  a  tumor  is  present  it  may  be  difficult  to  recognize  it, 
as  a  hydronephrotic  sac  may  be  mistaken  for  other  pelvic  tumors,  and 
other  diseases  of  the  kidneys  may  give  rise  to  a  similar  tumefaction. 
Among  such  conditions  may  be  mentioned  cysts  of  the  ovaries 
and  spleen,  echinococcus-cysts  of  the  liver  and  kidney,  and  simple 
cysts  or  polycystic  degeneration  of  the  kidney.  For  the  purpose 
of  differential  diagnosis  an  exploratory  puncture  may  be  made, 
if  possible,  by  the  extraperitoneal  route;  the  result  of  this  procedure, 
however,  is  by  no  means  positive,  for  hydronephrotic  fluid  usually 
does  not  contain  urea,  and,  on  the  other  hand,  urea  has  been  found 
in  the  fluid  of  ovarian  cysts. 

In  doubtful  cases  recourse  should  be  had  to  catheterization  of  the 
ureters,  although  this  method  naturally  cannot  always  lead  to  a 
certain  diagnosis.  If  the  hydronephrosis  is  closed  nothing  comes  out 
of  the  ureteral  catheter,  and  if  this  condition  obtains  upon  a  second 
trial  diagnosis  will  be  plain.  If  fluid  flows  out,  pressure  should  be 
made  upon  the  tumor  after  the  catheter  has  been  brought  near  to  the 
pelvis  of  the  kidney,  whereupon  the  outflow  may  be  seen  to  increase, 
although  in  some  cases  the  opposite  condition  is  observed,  the  stream 
stopping  suddenly,  the  passage  through  which  it  flows  being  occluded 
by  the  pressure  which  is  exerted. 

The  course  of  hydronephrosis  is  usually  very  slow,  particularly 
when  the  affection  is  unilateral.  The  disease  may  last  for  decades. 
It  is  only  when  the  outflow  of  urine  is  completely  shut  off  and  the 
kidney  continues  to  secrete  urine,  that  the  distention  becomes  so  great 
as  to  cause  pain  or  possibly  give  rise  to  attacks  of  colic. 

If  infection  of  the  sac  takes  place  pyonephrosis  develops,  although 
in  such  a  case  it  would  be  more  correct  to  use  the  term  infected  hydro- 
nephrosis.    When   this   condition   supervenes   it   may  cause   violent 


HYDRONEPHROSIS.  509 

disturbances  and  thus  transform  the  clinical  picture  into  one  of  great 
severity. 

The  prognosis  of  hydronephrosis  is  bad  as  to  cure,  as  it  is  seldom 
possible  to  remove  the  cause  of  the  obstruction;  as  to  life  it  is  favorable, 
because,  as  has  already  been  stated,  the  condition  may  go  on  for 
years,  until  so  much  of  the  renal  substance  is  destroyed  that  the  system 
begins  to  be  affected.  The  other  kidney  then  performs  a  vicarious 
function. 

Treatment.  As  obstruction  to  the  outflow  of  urine  is  the  cause  of 
hydronephrosis,  the  chief  object  of  treatment  is  to  secure  the  removal 
of  the  obstruction.  This  is  a  task,  however,  which  cannot  always  be 
performed.  Congenital  hydronephrosis  offers  especial  difficulties  in 
this  respect,  since  the  nature  of  the  obstruction  is  hard  to  diagnosticate. 

In  intermittent  hydronephrosis  caused  by  displacement  of  the  kidney 
the  prospects  of  cure  are  good,  as  in  many  cases  nephropexy  perma- 
nently removes  the  obstruction.  The  kidney  should  be  fastened  as 
high  up  as  possible,  so  that  the  ureter  may  be  stretched. 

Instead  of  passing  sutures  through  the  substance  of  the  kidney,  as 
was  formerly  the  custom,  I  now  practise  decapsulation  of  the  kidney 
exclusively  and  find  that  it  gives  excellent  results.  A  question  will 
naturally  arise  as  to  whether  milder  measures  will  not  afford  relief. 
Occasionally  the  kidney  can  be  retained  in  place  by  bandages  so  that 
kinking  of  the  ureter  will  not  occur,  although  this  is  exceptional. 

Too  much  must  not  be  expected  from  catheterization  of  the  ureters. 
It  has  been  attempted  to  stretch  the  ureter  by  leaving  the  ureteral 
catheter  in  situ,  and  in  a  few  cases  the  undertaking  has  proved  suc- 
cessful. I  do  not,  however,  favor  the  procedure,  as  it  is  very  difficult 
to  prevent  infection  of  the  hydronephrotic  sac  when  a  catheter  remains 
in  the  ureter  for  a  considerable  lime.  Although  there  is  little  danger 
of  infection  when  ureteral  catheterization  is  quickly  performed  and 
completed,  it  is  almost  sure  to  take  place  when  the  catheter  is  allowed 
to  remain  in  the  ureter  for  a  long  time.  Whether  frequently  repeated 
irrigation  of  the  pelvis  of  the  kidney  will  prevent  infection,  as  is  the  case 
with  irrigation  of  the  bladder  when  continuous  catheterization  is 
being  practised,  can  be  learned  only  by  experience. 

In  those  cases  in  which  an  operable  condition  in  the  pelvis,  for  in- 
stance, retroflexion  of  the  uterus,  is  causing  compression  of  the  ureter, 
the  obstruction  can  be  readily  removed.  In  most  other  cases  operation 
upon  the  kidney  itself  must  be  resorted  to,  as  simple  puncture  of  the 


510  DISEASES    OF    THE    KIDNEYS. 

sac  will  not  do  any  good.  The  injection  into  the  punctured  sac  of 
irritating  substances  such  as  iodine,  arsenic  and  alcohol  is  too  danger- 
ous to  be  used;  it  can  easily  lead  to  suppuration. 

Before  deciding  upon  operation  the  question  as  to  whether  operative 
interference  is  actually  indicated  must  be  carefully  weighed.  Many 
cases  of  hydronephrosis  cause  no  trouble;  they  increase  so  slowly 
that  the  general  health  remains  good  for  many  years.  Therefore  such 
cases  should  not  be  operated  upon,  particularly  if  they  are  unilateral. 
When  bilateral  hydronephrosis  is  present  the  fact  that  the  kidneys 
are  being  slowly  subjected  to  pressure-atrophy  must  be  taken  into 
account. 

In  regard  to  the  operation  itself,  it  has  been  found  that  simply  anchor- 
ing the  kidney,  as  was  formerly  practised,  will  not  produce  a  cure; 
we  have  to  do  with  a  large  sac  caused  by  distention  of  the  renal  pelvis 
and  consequent  destruction  of  renal  tissue,  and  for  this  reason  nephrot- 
omy, combined  perhaps  with  plastic  operations  on  the  kidney,  is  the 
rational  procedure.  Simple  pyelotomy  and  pyelostomy  should  be 
entirely  abandoned  because  they  are  too  frequently  followed  by 
fistulse,  which  are  more  annoying  to  the  patient  than  the  hydronephrosis 
for  which  the  operation  was  performed. 

Nephrectomy  is  usually  not  permissible;  at  present  the  tendency 
is  not  to  sacrifice  portions  of  renal  tissue  which  are  functionally  active 
and  therefore  useful  to  the  economy.  The  plastic  operations  on  the 
pelvis  of  the  kidney — pyeloplication,  uretero-pyelostomy,  resection  of 
the  ureter  and  anastomosis  of  the  cut  end  into  the  pelvis  of  the  kidney — 
are  still  in  the  stage  of  development,  but  they  offer  prospects  of  success 
and  should  usually  be  tried.  Nephrectomy  should  be  performed 
only  when  operation  shows  that  very  little  renal  tissue  remains,  or  that 
the  remaining  portion  is  much  diseased.  It  must,  of  course,  be  posi- 
tively determined  that  the  functional  capacity  of  the  other  kidney  is 
good.     In  such  cases  nephrectomy  gives  good  results. 

PYONEPHROSIS. 

Owing  to  the  multiplicity  of  terms  applied  to  suppuration  in  the 
kidney  it  is  necessary  to  have  a  clear  conception  of  what  is  meant  by 
pyonephrosis.  In  accordance  with  the  mode  of  development,  two 
forms  may  be  distinguished,  one  of  which  has  already  been  spoken  of 
as  infected  hydronephrosis.     If  the  urine  in  a  distended  renal  pelvis, 


PYONEPHROSIS.  511 

which  has  been  formed  principally  at  the  expense  of  the  renal  tissues, 
becomes  infected,  suppuration  develops  in  the  sac  and  slowly  invades 
the  parenchyma  of  the  kidney.  In  the  second  group  an  ascending 
suppurative  process  involves  the  parenchyma  of  the  kidney,  which  was 
previously  healthy,  and  causes  its  destruction,  without,  however,  pro- 
ducing distention  of  the  renal  pelvis;  it  is  these  cases  which  the  French 
call  pyelonephritis  without  distention  (pyelonephrite  sans  distention) 
and  which  Israel  terms  primary  pyonephrosis  (originare  pyonephrose). 
Finally,  belonging  to  the  second  group  are  those  cases  in  which  primary 
infection  of  the  parenchyma  of  the  kidney  takes  place  without  involving 
the  pelvis,  and  therefore  without  producing  distention.  Thus  it  is 
seen  that  infection  is  the  result  of  haematogenous  pyelonephritis. 

Primary  pyelonephrosis  is  generally  a  sequel  of  cystitis.  The  latter 
disease  extends  to  the  ureter  and  produces  ureteritis  with  thickening 
of  the  walls,  which  causes  loss  or  diminution  of  their  contractility. 
As  a  result  of  these  changes  the  caliber  of  the  ureter  becomes  lessened, 
and  consequently  there  is  a  tendency  for  the  secretion  in  the  pelvis 
of  the  kidney  to  become  stagnant.  If  the  ascending  infection  produces 
a  pyelitis  or  pyelonephritis,  pyonephrosis  will  develop  in  consequence 
of  the  changes  in  the  ureter. 

These  ascending  forms  of  urinary  infection  are  met  with  very  fre- 
quently in  pregnant  and  puerperal  women  and  may  occur  quite  inde- 
pendently of  catheter-infection;  they  also  occur  as  the  result  of 
ascending  gonorrhoea,  although  it  has  not  yet  been  determined 
whether  they  are  due  to  the  gonococcus  alone  or  to  mixed  infection. 
This  form  frequently  affects  only  one  kidney. 

The  form  due  to  infection  of  retained  fluid  in  the  renal  pelvis  has 
been  described  in  connection  with  hydronephrosis.  These  dilated 
aseptic  sacs  may  become  infected  either  by  an  ascending  or  a  hsema- 
togenous  infection.  The  first  usually  follows  some  obstructive  con- 
dition in  the  urinary  system,  such  as  stricture  of  the  urethra,  hyper- 
trophy of  the  prostate,  paralysis  or  tumors  of  the  bladder;  the 
latter  occurs  in  association  with  general  infections  such  as  pyaemia, 
typhoid  fever,  small  pox,  osteomyelitis,  etc.  As  has  already  been 
stated,  haematogenous  infection  may  also  give  rise  to  primary  suppura- 
tion in  the  parenchyma  of  the  kidney  without  previously  involving 
the  pelvis. 

Pathological  Anatomy.  Although  the  origin  of  pyonephrosis  is 
most  diverse  and  the  appearance  of  the  different  forms  about  to  be 


512  DISEASES    OF    THE    KIDNEYS. 

described  is  very  different,  the  presence  of  foci  of  suppuration  within 
the  substance  of  the  kidney  is  common  to  them  all ;  moreover,  a  greater 
or  less  degree  of  inflammation  in  the  renal  parenchyma  not  yet  destroyed 
by  the  suppurative  process  is  also  invariably  present. 


Fig.  222. — Pyonephrotic  kidney  weighing  forty-five  pounds.     (N.  T.  Brewis.) 

The  size  of  pyonephrotic  kidneys  is  most  variable  (Fig.  222) .    Infected 
hydro-nephroses  are  usually  larger  than  the  primary  variety,  and  as  a 


PYONEPHROSIS.  513 

rule  are  so  deeply  situated  that  they  are  not  accessible  to  palpation; 
the  latter  variety  also  often  lies  concealed  beneath  the  thorax. 

The  mucous  membrane  of  the  renal  pelvis  shows  the  changes  of 
pyelitis.  It  is  maculated  or  reddened,  may  be  smooth  or  rough,  and 
also  cedematous,  and  is  sometimes  covered  with  fine  miliary  nodules 
which  at  first  glance  may  appear  to  be  tubercles,  but  which  in  reality 
are  either  collections  of  leucocytes  or  minute  areas  of  fatty  degenera- 
tion. 

The  kidney  tissue  itself  is  pale,  cloudy  and  friable.  It  contains 
small  yellow  foci,  which  may  attain  the  size  of  the  head  of  a  pin,  and 
which  represent  either  collections  of  leucocytes  or  minute  abscesses. 
The  latter  may  coalesce  and  form  larger  abscesses,  containing  creamy 
or  perhaps  sanious  pus,  in  which  are  found  sand,  gravel,  fragments 
of  calculi,  masses  composed  of  pus,  blood  and  epithelium,  and  others 
formed  of  triple  phosphate;  the  latter  may  attain  a  considerable  size. 

According  to  the  manner  in  which  the  disease  develops,  the  pelvis 
of  the  kidney  and  the  calices  are  dilated,  or  the  cavity  may  encroach 
upon  the  substance  of  the  kidney.  The  calices  are  often  as  large  as 
apples,  and  their  opening  into  the  pelvis  is  frequently  narrow,  in 
contradistinction  to  hydronephrosis,  in  which  the  dilated  calices  are 
usually  drawn  into  the  pelvis.  Around  the  hilus  there  often  develops 
pari  passu  with  the  destruction  of  the  substance  of  the  kidney  a  thick 
accumulation  of  fat,  which  often  is  so  extensive  that  it  converts  the 
entire  kidney  into  one  large  fatty  mass,  in  which  remnants  of  the 
parenchyma  and  a  few  cavities  filled  with  pus  may  be  seen  here  and 
there. 

If  the  process  of  granulation  extends  through  the  kidney  to  the 
fibrous  capsule,  perinephric  adhesions  are  formed  and  suppuration 
may  finally  occur.  The  suppurative  process  may  even  invade  the 
fatty  capsule  of  the  kidney  and  partly  destroy  it.  The  condition 
which  then  obtains  is  one  of  paranephric  suppuration. 

The  condition  of  the  ureters  depends  upon  whether  the  disease 
ascended  from  below  or  began  in  the  kidney.  In  the  ascending  form 
ureteritis  is  always  present,  and  if  it  develops  simultaneously  with 
obstructive  conditions  leads  to  thickening  of  the  walls,  particularly 
the  outer  layers,  and  converts  the  ureter  into  a  thick  tough  cord  which 
becomes  adherent  to  the  peritoneum. 

If  no  obstruction  exists,  an  ascending  ureteritis  having  produced 
pyelonephritis,  extensive  thickening  of  the  ureter  does  not  take  place, 
35 


514  DISEASES    OF    THE    KIDNEYS. 

although  circumscribed  areas  of  stenosis  due  to  plastic  exudate  are 
present.  In  infected  hydronephrosis  the  ureter  is  usually  dilated 
and  may  be  as  large  as  a  coil  of  intestine. 

It  is  of  practical  importance  to  remember  that  the  vessels  in  the 
pedicle  of  large  pyonephroses  often  have  an  abnormally  narrow 
lumen.  This  is  partly  due  to  functional  adjustment — the  vessels 
having  less  tissue  to  nourish — and  partly  to  endarteritis. 

Symptoms,  Course  and  Diagnosis.  The  clinical  picture  of  pyo- 
nephrosis is  most  variable,  thus  corresponding  to  the  heterogeneous - 
ness  of  the  underlying  morbid  anatomical  process.  Purulent  urine 
is  common  to  all  open  pyonephroses.  This  pyuria  exists  as  long 
as  there  is  an  open  channel  from  the  suppurating  renal  pelvis.  It 
may  cease  temporarily  or  permanently — temporarily  if  an  obstruction 
develops  in  the  kidney  or  ureter,  permanently  if  this  obstruction 
persists,  or  if  the  kidney  has  been  destroyed  by  suppuration,  so  that 
nothing  but  a  fatty  and  fibrous  mass  remains. 

Sudden  occlusion  of  a  pyonephrosis  almost  always  produces  a  con- 
stitutional reaction.  Although  the  patient  may  feel  perfectly  well  as 
long  as  the  pus  has  a  free  exit,  fever,  weakness  and  anorexia  develop 
as  soon  as  its  outflow  is  impeded.  Fever,  however,  may  be  present  in 
open  pyonephrosis,  although  I  have  found  it  absent  as  often  as  present. 
It  evidently  depends  upon  the  acuteness  of  the  inflammatory  and 
suppurative  process  going  on  in  the  parenchyma  of  the  kidney.  On 
the  other  hand,  occlusion  of  a  pyonephrosis  may  occur  without  pro- 
ducing fever.  The  urine  clears  up  and  remains  clear  as  long  as  the 
pyonephrosis  is  closed,  provided  that  the  second  kidney  is  not  secret- 
ing pus. 

Even  an  open  pyonephrosis,  however,  may  occasionally  fail  to 
produce  purulent  urine.  This  is  especially  true  of  infected  hydro- 
nephrosis. Owing  to  copious  discharge  of  pus  there  are  periods  in 
which  the  sac  becomes  so  well  cleansed  that  clear  urine  is  secreted 
for  some  time ;  then  after  another  obstruction  (twisting  of  the  ureter, 
etc.)  occurs,  accompanied  by  symptoms  of  colic,  pus  appears  again. 
These  cases  have  been  rightly  called  pyohydronephrosis. 

A  further  symptom  of  pyonephrosis  is  pain  in  the  renal  region. 
This  pain  may  develop  spontaneously  or  first  manifest  itself  upon 
pressure.  Spontaneous  renal  pain  is  absent  as  often  as  it  is  present. 
There  are  persons  having  a  large  suppurating  kidney-sac  who  are  not 
at  all  troubled  by  it.     Less  often  pressure  over  the  kidney  fails  to  cause 


PYONEPHROSIS.  515 

pain.  Usually  an  uncomfortable  feeling  is  experienced  which  is 
transformed  into  pain  when  pressure  is  made. 

Palpation  is  not  to  be  relied  upon.  A  greatly  distended  renal  sac 
can  usually  be  felt  when  it  lies  below  the  arch  of  the  ribs,  or  when  it  is 
brought  out  under  the  arch  by  a  deep  inspiration.  But  all  pyoneph- 
roses  are  not  very  large  and  all  do  not  lie  under  the  costal  arch.  I  have 
often  seen  cases  in  which  the  kidney  lay  concealed  under  the  thorax 
and  was  absolutely  inaccessible  to  palpation. 

If  all  the  symptoms  are  taken  together,  namely,  the  pyuria  which 
persists  despite  all  internal  and  local  treatment,  the  absence  of  vesical 
symptoms,  the  pain  upon  pressure,  the  development,  perhaps,  of  a 
tumor,  the  constitutional  reaction,  and  in  addition  to  these  the  evolu- 
tion of  the  malady,  diagnosis  can  usually  be  made:  under  such  cir- 
cumstances there  is  suppuration  in  the  kidney. 

Further  examination  must  then  be  made  to  determine,  which  kidney 
is  suppurating  and  to  ascertain  if  the  other  kidney  is  in  a  condition  to 
permit  operation.  Ofttimes  the  cystoscopic  picture  will  show  which 
kidney  is  secreting  clear  and  which  purulent  urine.  If  it  cannot  be 
determined  in  this  manner  ureteral  catheterization  should  be  tried. 
A  catheter  should  be  introduced  into  the  ureter  on  the  presumably 
diseased  side  and  an  ordinary  urethral  catheter  passed  into  the  blad- 
der so  as  to  collect  the  urine  from  the  other  kidney.  This  method 
of  examination  shows  precisely  which  kidney  secretes  clear  and  which 
cloudy  urine.  It  also  shows  whether  the  second  kidney  is  healthy  and 
how  it  is  working.  The  question  as  to  how  healthy  it  is  and  whether 
it  is  working  with  sufficient  activity  can  be  determined  by  the  functional 
examination  {quod  vide). 

A  typical  example  of  unilateral  pyonephrosis  with  well  preserved 
functional  activity  of  the  other  kidney  is  the  following: 

Ureteral  Catheterization.     Phloridzin  o.oi. 

R.  L. 

Urine:         Cloudy  with  thick  flocculi.  Cloudy;  acid. 

Sediment:  Pus.  None 

Albumen:   Corresponding  to  the  Pus.  None 

A                          -0.48  0.96 

Sugar:                       o  0.8 

Finally,  as  concerns  the  differential  diagnosis  of  pyonephrosis  from 
other  tumors  in  the  ■  abdominal  cavity,  it  may  be  stated  that  the  great 


516  DISEASES    OF   THE    KIDNEYS. 

difficulties  which  formerly  prevailed  have  been  overcome  by  ureteral 
catheterization.  The  ureteral  catheter  shows  the  source  of  the  pus  to 
be  directly  from  the  kidney. 

The  prognosis  and  course  of  the  disease  usually  depend  upon  the 
rapidity  with  which  the  suppuration  advances  and  whether  it  is  bilat- 
eral or  unilateral.  In  the  latter  instance  the  prognosis  is  much  better 
than  in  the  former.  Such  cases  may  last  for  years  without  affecting 
the  general  health.  It  happens  more  often,  however,  that  some  dis- 
turbance is  produced;  the  principal  one  is  toxic  nephritis  of  the  other 
kidney,  caused  by  the  resorption  of  pus. 

It  has  already  been  stated  that  cure  may  occur  without  intervention, 
the  whole  kidney  suppurating  and  being  converted  into  a  fatty,  fibrous 
mass;  such  a  termination,  however,  is  exceptional,  and  is  not  to  be 
expected.  It  is  much  more  common  for  the  suppuration,  if  left  to 
itself,  to  invade  the  tissues  around  the  kidney  and  cause  perinephritis 
or  paranephritis  {quod  vide). 

The  treatment  of  pyonephrosis  differs  with  the  nature  of  the  morbid 
process  present,  its  extent,  and  whether  it  affects  one  or  both  kidneys. 
Internal  treatment  is  not  to  be  thought  of  unless  both  kidneys  are  so 
diseased  that  operative  treatment  cannot  be  employed.  In  cases 
suitable  for  operation  internal  treatment  should  be  entirely  discarded, 
for  it  will  never  succeed  in  rendering  an  infected  renal  sac  aseptic. 
The  exceptional  cases  of  spontaneous  cure  above  mentioned  are  ex- 
cluded from  this  rule. 

Accordingly  the  focus  of  suppuration  must  be  attacked.  This  can 
be  done  in  two  ways,  either  by  irrigating  through  a  ureteral  catheter 
introduced  into  the  pelvis  of  the  kidney,  or  by  incising,  or  perhaps 
removing,  the  kidney. 

In  regard  to  the  irrigation  method  its  usefulness  is  very  limited,  and 
it  is  applicable  only  in  cases  of  infected  hydronephrosis.  I  have  cured 
two  such  cases  in  which  the  renal  pelvis  was  converted  into  a  large 
pus-sac  by  irrigating  with  nitrate  of  silver  solution  (i-iooo).  In 
these  cases'  the  method  may  be  tried. 

In  cases  in  which  the  substance  of  the  kidney  is  involved  and  per- 
meated with  abscess  cavities,  which  perhaps  do  not  communicate  with 
the  pelvis  of  the  kidney,  or  at  most  open  into  it  by  very  narrow  outlets, 
irrigation  is  useless.  Hence  before  the  irrigation  method  is  employed 
it  is  necessary  to  make  an  exact  diagnosis,  so  that  one  may  be  sure  that 
he  is  dealing  with  an  infected  hydronephrosis  and  not  a  primary  or 


TUBERCULOSIS    OF    THE    KIDNEY. 


517 


secondary  pyonephrosis;  this  can  usually  be  done  by  functional  renal 
examination. 

If  irrigation  fails  to  give  prompt  results  no  time  should  be  wasted 
with  it.  It  can  soon  be  learned  whether  a  case  is  suitable  for  this 
treatment,  as  the  pus  begins  to  dimmish  after  a  few  irrigations.  In 
case  no  benefit  is  derived  nothing  but  operation  (nephrotomy  or  neph- 
rectomy) will  suffice. 

The  former  is  particularly  indicated  in  infected  hydronephrosis  in 
which  a  great  deal  of  renal  tissue  is  still  preserved,  whereas  when 
typical  abscesses  are  present  in  the  parenchyma,  nephrectomy  is  to  be 
preferred  on  account  of  the  danger  of  fistulae  incident  to  nephrotomy, 
provided  always  that  the  condition  of  the  second  kidney  warrants 
intervention. 

If  the  second  kidney  is  seriously  diseased  and  its  function  poor  I 
also  consider  nephrotomy  contraindicated,  for  it  is  also  a  serious  opera- 
tion; in  addition  to  the  danger  it  involves  it  offers  little  advantage, 
because  very  annoying  fistulae  are  apt  to  remain  after  its  performance. 
Such  cases,  therefore,  are  to  be  considered  inoperable. 

TUBERCULOSIS  OF  THE  KIDNEY  (NEPHROPHTHISIS). 

Tuberculosis  of  the  kidney  may  be  one  of  many  localizations  of  general 
tuberculosis.  As  such  it  is  naturally  not  subject  to  special  treatment. 
The  disease  may  also  affect  the  kidney  only,  or  be  confined  to  it  and 
a  few  other  organs. 

It  was  formerly  believed  that  most  cases  of  renal  tuberculosis  were 
due  to  ascending  infection,  but  this  is  not  the  case,  such  a  manner  of 
development  being  decidedly  exceptional.  The  rule  is  primary 
hematogenous  nephrophthisis. 

In  simultaneous  localization  in  the  genital  system,  for  example,  in 
the  epididymis,  tuberculosis  may  ascend  from  the  bladder,  but  it  is 
important  to  know  that  both  epididymis  and  kidney  are  favorite  sites 
for  the  localization  of  hasmatogenous  tuberculous  infection.  In  this 
case  the  bladder  is  not  involved. 

In  women  the  ascending  form  has  rarely  been  observed;  in  men  it 
is  more  common,  but  it  occurs  much  less  frequently  than  the  hasmatog- 
enous form.  In  men  it  is  not  unusual  to  find  associated  tuberculous 
disease  of  the  sexual  and  urinary  organs.  Renal  tuberculosis  is  most 
common  between  the  twentieth  and  fortieth  years;  before  twenty  and 
after  forty  it  is  rare. 


51 8  DISEASES    OF   THE    KIDNEYS. 

Pathological  Anatomy.  In  primary  renal  tuberculosis  cavities 
are  generally  found,  which  are  formed  by  softening  and  liquefaction  of 
masses  of  caseated  tubercles.  Occasionally  a  kidney  is  found  at  oper- 
ation presenting  numerous  isolated  nodules  that  have  not  yet  under- 
gone liquefaction.  The  cavities  are  characterized  by  their  ragged 
walls  and  irregular  size.  Surrounding  them  is  an  area  of  granulation 
tissue.  In  the  columns  of  kidney  tissue  which  separate  the  cavities 
there  are  many  fresh  or  perhaps  already  caseated  tubercles;  they  are 
also  present  on  the  surface,  both  above  and  beneath  the  true  capsule, 
where  they  appear  as  fine  nodules.  It  is  worthy  of  notice  that  the 
disease  is  sometimes  distinctly  isolated,  being  confined  to  one  pole  of 
the  kidney.  Zondeck  thinks  this  is  due  to  the  fact  that  the  pole  of 
the  organ  receives  a  separate  blood  supply. 

As  time  elapses  the  tubercles  in  the  kidney  encroach  upon  contiguous 
structures.  Both  true  and  fatty  capsules  are  converted  into  thick 
connective  and  lardaceous  tissue,  or  else  a  suppurative  perinephritis 
is  produced  owing  to  extension  by  continuity  of  the  liquefactive  tuber- 
culous process  to  the  capsule;  in  some  cases  the  connective  tissue 
between  the  kidney  and  its  capsule  may  escape,  the  infection  being 
carried  to  the  capsule  through  the  lymphatics.  More  rarely  the 
parenchyma  of  the  kidney  remains  free,  tuberculous  ulceration  of 
the  surface  of  the  papillae  being  the  only  lesion  present. 

In  primary  tuberculosis  of  long  duration  the  ureters  invariably  be- 
come diseased.  Simple  or  tuberculous  inflammation  is  produced,  with 
the  result  that  the  walls  become  thickened,  the  canal  stenotic,  and 
converted  into  a  firm  cord  which  is  adherent  to  the  surrounding  tissue. 
This  condition  is  known  as  sclerosing  periureteritis  (Fig.  223).  If 
the  process  is  tuberculous  lenticular  ulcers  and  nodules  are  frequently 
seen  on  the  ureteral  mucosa. 

In  like  manner  the  bladder  may  also  be  affected  with  tuberculous  or 
simple  inflammation.  Unfortunately  the  latter  form  is  rare.  When 
the  bladder  is  tuberculous,  swelling,  redness,  displacement  and  ulcer- 
ation of  the  ureteral  orifices  are  seen.  The  surrounding  tissue  is  also 
inflamed.  Occasionally  disseminated  tubercles  are  found  in  this 
region,  whereas  in  simple  inflammatory  cystitis  the  changes  are  more 
diffuse,  extending  over  the  whole  bladder. 

Of  great  importance  is  the  circumstance  that  renal  tuberculosis  is 
often  unilateral,  and  that  when  it  is  bilateral  it  has  frequently  been 
transmitted  to  the  second  kidney  from  the  first.     In  addition  to  tuber- 


TUBERCULOSIS    OF    THE    KIDNEY. 


519 


culosis  other  pathic  processes  are  even  more  frequently  met  with,  par- 
ticularly amyloid  degeneration,  chronic  nephritis,  or  granular  atrophy. 
It  is  evident  that  in  primary  renal  tuberculosis  other  organs,  such  as 


-e 


Fig.  223.— Tuberculosis  of  the  kidney  and  ureter,     a.  Cicatricial  narrowing  of  the 
ureter,     b.  Lower  end  of  the  divided  ureter,     c.c.  Dilated  calices  with  tubercles. 


the  epididymis,  prostate,  seminal  vesicles,  lungs,  joints,  and  vertebrae 
may  also  be  diseased.  It  must  not,  therefore,  be  assumed  that  an 
associated  genital  tuberculosis  signifies  an  ascending  renal  tuberculosis. 


520  DISEASES    OF    THE    KIDNEYS. 

In  the  latter  case  genuine  tuberculous  disease  of  the  bladder  and  ureter 
will  always  be  found. 

Symptoms  and  Diagnosis.  As  in  other  localizations  of  tubercu- 
losis, so  in  the  renal  form,  every  symptom  may  be  wanting  in  the 
beginning  stages  of  the  disease.  It  does  not  betray  its  presence  in 
any  way  whatsoever,  not  even  by  a  phthisical  habit.  Soon,  however, 
it  makes  itself  plainly  evident;  constitutional  disturbances,  a  palpable 
renal  tumor,  and  unmistakable  alterations  in  the  urine  make  the  na- 
ture of  the  affection  plain. 

The  general  health  becomes  considerably  impaired;  the  patient 
may  either  be  free  from  fever  or  suffer  with  the  intermittent  hectic 
fever  typical  of  tuberculous  infection.  In  the  first  instance  emaciation 
and  the  livid  sallow  appearance  characteristic  of  these  patients  comes 
on  gradually,  whereas  in  the  latter  their  development  is  more  rapid. 

The  enlargement  of  the  kidney  seldom  escapes  detection  upon 
palpation,  although  it  usually  is  not  so  great  as  in  non-tuberculous 
pyonephrosis.  In  cases  in  which  no  distinct  swelling  was  present  I 
have  often  found  the  renal  region  on  the  affected  side  to  be  more 
resistant  and  distended  than  in  health.  This  evidently  is  due  to  the 
fact,  that  the  kidney  and  its  capsule  are  surrounded  by  adhesions,  in 
consequence  of  which  it  becomes  increased  in  size.  For  the  same 
reason  the  tuberculous  kidney  is  frequently  found  to  be  less  movable 
than  the  healthy  kidney  and  other  renal  tumors.  The  enlarged  kidney 
either  gives  rise  to  pain  spontaneously,  the  patients  experiencing  a  dull, 
heavy  feeling  in  the  lumbar  region,  or  distinct  pain  is  produced  upon 
pressure. 

The  urine  contains  pus  in  varying  quantities,  and  also  occasionally 
crumbling  caseous  masses  in  which  many  tubercle  bacilli  are  sometimes 
found,  although  they  may  be  entirely  absent.  The  albumen-content 
depends  upon  the  ofttimes  simultaneous  nephritic  process  which  is 
present  in  those  portions  of  the  kidney  which  have  not  yet  become 
tuberculous.  Blood-corpuscles  are  seldom  absent;  macroscopic 
haemorrhages,  however,  are  of  rare  occurrence.  If  the  tuberculous 
foci  have  not  broken  through  into  the  pelvis  of  the  kidney,  or  if  the 
ureter  is  obliterated  or  obstructed,  the  urine  may  be  perfectly  clear 
and  thus  cause  errors  in  diagnosis. 

If  the  bladder  is  involved  typical  symptoms,  dysuria,  strangury 
and  tenesmus,  are  present,  although  it  is  noteworthy  that  these  vesical 
manifestations  may  also  be  caused  by  the  renal  disease,  particularly 


TUBERCULOSIS    OF    THE    KIDNEY.  52 1 

when  the  pelvis  is  affected,  the  bladder  being  neither  tuberculous  nor 
highly  inflamed. 

Thus  it  is  seen  that  the  diagnosis  of  renal  tuberculosis  may  present 
great  difficulties.  In  order  to  make  it  clear  auxiliary  measures  may 
have  to  be  employed. 

A  very  careful  history  should  be  obtained,  and  evidences  of  tuber- 
culosis sought  for  in  other  parts  of  the  body,  in  the  glands,  lungs, 
joints,  epididymes,  seminal  vesicles,  etc.  It  must  be  remembered  that 
tuberculosis  may  be  superimposed  upon  an  old,  uncured  gonorrhoea. 
I  have  seen  many  cases  of  gonorrhceal  pyelitis  develop  into  tuberculosis 
of  the  kidney. 

On  the  other  hand  renal  suppuration  for  which  no  cause  can  be 
found  represents  one  type  of  renal  tuberculosis.  Pyuria  which  fails 
to  improve  under  appropriate  treatment  should  arouse  suspicion  that 
the  trouble  is  not  in  the  bladder  but  in  the  kidney.  The  determination 
of  the  seat  of  suppuration  is  a  step  in  advance.  Whether  it  is  tuber- 
culous naturally  has  to  be  learned  by  other  methods  of  examination. 
Tubercle  bacilli  are  found  in  70%  to  80%  of  all  cases  in  which  thorough 
examination  is  made.  If  they  are  not  found  and  suspicion  that  the 
disease  is  tuberculous  still  remains,  guinea-pigs  should  be  inoculated 
in  the  peritoneal  cavity  with  some  of  the  purulent  urinary  sediment. 
After  five  or  six  weeks  postmortem  examination  of  the  guinea  pigs 
will  reveal  in  positive  cases  the  presence  of  an  acute  miliary  tubercu- 
losis. 

Of  material  assistance  in  diagnosis  are  cystoscopy  and  catheterization 
of  the  ureters.  If  there  is  purulent  urine  which  fails  to  become  clear 
under  proper  treatment,  and  if  cystoscopic  examination  reveals  a  com- 
paratively healthy  bladder,  it  may  be  concluded  that  the  pus  comes 
from  the  kidney.  If  the  orifices  of  the  ureters  are  then  observed,  tur- 
bid fluid  will  often  be  seen  issuing  from  one  or  both  of  them. 

Occasionally  characteristic  changes  are  present  in  the  ureteral  pap- 
illae. It  is  highly  vascular  and  its  edges  are  distorted,  being  either  in- 
verted or  everted,  and  covered  with  minute  ulcers  or  areas  of  capillary 
haemorrhage.  In  order  to  remove  all  doubt  and  to  determine  whether 
the  affection  is  unilateral  or  bilateral,  the  ureteral  catheter  may  be 
employed;  this  will  clear  up  the  situation  at  once,  though  it  naturally 
will  not  reveal  the  nature  of  the  suppurative  process  unless  tubercle 
bacilli  are  found  in  the  urine  obtained  by  its  use. 

The  following  are  characteristic  examples  of  the  urine  obtained  by 


522  DISEASES    OF    THE    KIDNEYS. 

catheterization  of  the  ureters  in  unilateral  and  bilateral  renal  tuber- 
culosis. 

1.  TUBERCULOSIS      OF      THE     RIGHT     KIDNEY.       CATHETERIZATION     OF 

THE    URETERS.       (o.OI    PHLORIDZLN.) 

Right.  Left. 

Urine  turbid.  Clear. 
Albumen:  A  heavy  ring  upon  addition  of  nitric  acid 

to  the  filtered  urine.  None 

Sediment:  Pus  and  tubercle  bacilli.  None 

A  0.94  1.44 

Sugar:  2.4  4.0 

This  is  a  case  of  beginning  tuberculosis,  as  is  shown  by  the  relatively 
good  functional  power  of  the  right  kidney. 

2.  BILATERAL      RENAL     TUBERCULOSIS.        CATHETERIZATION     OF     THE 

URETERS.       (O.I    PHLORIDZLN.) 

Right.  Left. 

Urine  turbid.  Urine  turbid 

Albumen:  0.01%  0.15 

Sediment:  Pus  and  tubercle  Pus  and  tubercle 

bacilli.  bacilli 

A              0.5  0.43 

Sugar:        A  trace.  o 

This  was  a  case  of  advanced  and  inoperable  bilateral  renal  tubercu- 
losis. 

In  general  the  prognosis  of  tuberculosis  of  the  kidney  is  unfavorable. 
It  depends  materially  upon  the  stage  in  which  the  patient  comes  under 
treatment.  If  the  affection  is  bilateral  and  other  tuberculous  foci  are 
present  in  the  body,  the  prognosis  is  considerably  worse  than  it  other- 
wise would  be.  On  the  contrary,  unilateral  cases  which  come  under 
observation  early  offer  a  good  prognosis,  the  patients  usually  regaining 
their  health  after  the  diseased  kidney  has  been  removed.  The  course 
of  inoperable  cases  is  rather  slow.  They  last  a  long  time,  often  for 
many  years,  before  the  parenchyma  of  the  kidney  is  so  destroyed  that 
signs  of  renal  insufficiency  manifest  themselves.  As  a  rule,  metastases 
and  general  dissemination  of  tuberculosis  occur  and  cause  death. 

Extension  of  the  tuberculous  process  to  the  perinephric  and  para- 
nephric tissues  is  not  uncommon.     It  extends  along  the  fibrous  and 


TUBERCULOSIS    OF    THE    KIDNEY.  523 

fatty  capsule,  perforates  these  structures  and  advances  toward  the 
exterior,  producing  suppuration  limited  only  by  the  superficial  tissues. 
This  course  usually  produces  acute  symptoms,  consisting  of  painful 
swelling  in  the  region  of  the  kidney,  high  fever,  and  general  constitu- 
tional disturbance. 

In  severe  cases  in  which  both  kidneys  are  tuberculous  or  in  which 
one  is  tuberculous  and  one  nephritic  or  amyloid,  or  in  those  cases  in 
which  numerous  other  tuberculous  foci  exist,  treatment  may  be  merely 
symptomatic,  and  confined  to  the  relief  of  the  patient's  suffering. 
Nutritious  food,  avoidance  of  all  injurious  influences,  occasional 
irrigation  of  the  bladder,  and  the  administration  of  urotropin  and 
narcotics  are  the  proper  measures. 

If  tuberculosis  of  one  kidney  is  detected  early  enough  I  recommend 
removal  of  the  diseased  organ  in  its  entirety.  Operation  has  been 
advised  against  in  cases  in  which  the  disease  was  recognized  and  in 
which  signs  of  tuberculosis  could  not  be  detected  in  any  other  organ, 
for  the  reason  that  spontaneous  cures  occasionally  occur;  they  are  so 
unusual,  however,  that  they  should  not  be  relied  upon.  In  the  great 
majority  of  all  cases  it  is  rather  to  be  expected  that  the  disease  will 
advance,  that  the  kidney  will  become  more  and  more  destroyed, 
and  that  other  organs,  particularly  the  opposite  kidney,  will  become 
involved.  It  is  inflammation  or  amyloid  degeneration  of  the  second 
kidney  which  renders  prognosis  unfavorable.  Therefore  operation 
should  be  done  before  these  complications  become  established.  More- 
over, I  have  obtained  very  gratifying  results  from  early  extirpation  of 
the  kidney. 

Moderate  involvement  of  the  bladder  or  lungs  is  not  a  contraindica- 
tion to  operation;  experience  has  taught  that  the  bladder  will  heal, 
or  at  least  improve,  if  the  source  of  the  tuberculous  material,  which 
in  this  case  is  the  kidney,  be  removed. 

I  advise  against  partial  resection  of  the  kidney.  Our  knowledge 
of  the  results  obtained  by  this  procedure  is  insufficient.  Furthermore, 
it  is  often  impossible  to  determine  whether  a  destroyed  tuberculous 
focus  is  the  only  one  present  in  the  kidney.  Section  of  the  kidney 
will  not  solve  the  question,  for  although  it  may  appear  healthy,  multiple 
concealed  tuberculous  foci  may  be  contained  within  the  parenchyma. 

Perinephric  suppuration  originating  from  a  tuberculous  kidney 
always  requires  surgical  intervention,  which,  however,  must  often  be 
confined  to  opening  the  abscess. 


524  DISEASES    OF    THE    KIDNEYS. 

RENAL  AND  URETERAL  CALCULI  (NEPHROLITHIASIS). 

We  know  as  little  about  the  causes  of  renal  calculi  as  we  do  concerning 
those  of  stone  in  the  bladder.  If  normal  or  abnormal  constituents 
of  the  urine  fail  to  remain  soluble,  but  are  precipitated  upon  an  organ- 
ized stroma,  the  prerequisites  for  the  development  of  a  calculus  are 
supplied  (Ebstein,  Posner). 

If  the  precipitate  is  very  fine  and  meal-like  it  is  spoken  of  as  renal 
sand,  while  if  it  is  larger,  like  wheat  or  millet-seed,  it  is  known  as  gravel. 
If  it  occurs  in  the  form  of  large  masses  it  is  called  renal  stone.  In  size 
these  stones  vary  from  that  of  a  lentil  to  a  pigeon's  egg.  If  tooth-like 
prolongations  project  into  the  calices,  the  so-called  coral  stones  are 
formed.  As  a  rule,  the  larger  the  calculi  the  fewer  their  number. 
Small  calculi  from  the  size  of  a  lentil  to  that  of  a  bean  occur  in  large 
numbers  in  the  pelvis  of  the  kidney. 

The  stones  may  be  either  primary  or  secondary.  To  the  first  class 
belong  those  composed  of  uric  acid,  urates,  or  a  combination  of  the  two, 
which  are  characterized  by  their  red  color;  those  made  up  of  oxalate 
of  lime,  which  vary  in  color  from  gray  to  blackish-brown  and  have 
rough  spiny  surfaces;  and  finally  the  rare  soft  cystin  calculi  and  the 
even  rarer  hard  xanthin  stones. 

The  secondary  calculi  are  composed  of  phosphate  and  carbonate  of 
lime  and  phosphate  of  magnesia,  these  salts  being  deposited  upon  a 
foreign  body  (mucus,  pus,  blood).  In  exceptional  cases  these  stones 
may  also  be  primary. 

Mixed  stones  are  those  which  contain  several  of  these  substances. 
Thus  there  are  some  having  a  deposit  of  oxalates  around  a  nucleus 
of  urates,  and  others  with  a  layer  of  phosphates  superimposed  upon  a 
nucleus  of  oxalates. 

Nephrolithiasis  is  most  common  in  advanced  age  and  early  child- 
hood. Persons  in  middle  life  are  comparatively  free  from  it.  Men  are 
affected  more  often  than  women.  Heredity  and  diet  have  some 
influence,  but  exactly  what  it  is  has  not  yet  been  determined.  Thus 
in  many  respects  the  disease  rests  upon  an  unknown  foundation. 
{Compare  with  the  remarks  on  the  causes  of  vesical  calculi.) 

Pathological  Anatomy.  In  a  few  exceptional  cases  renal  calculi 
do  not  produce  any  changes  in  the  kidney  and  its  pelvis.  They  lie 
as  aseptic  foreign  bodies  in  the  pelvis  of  the  kidney,  and  if  they  occlude 
the  opening  of  the  ureter  give  rise  to  an  aseptic  retention  of  urine, 
which  upon  long  duration  or  frequent  repetition  may  produce  hydro- 


RENAL  AND  URETERAL  CALCULI. 


525 


nephrosis.  In  the  majority  of  cases,  however,  they  lead  to  chronic 
inflammation  of  the  interstitial  tissue  of  the  kidney  and  to  hyperplastic 
changes  in  the  capsule  and  hilus. 

Israel  recognizes  the  large  firm  calculous  kidney,  in  which  hyper- 
plastic fibrinous  overgrowth  of  the  capsule,  periglomerulitis  and  peri- 
vascular thickening  are  responsible  for  the  enlargement  of  the  organ; 
and  the  contracted  calculous  kidney,  in  which  the  epithelium  atrophies 


c    t ,-*-•_ 


f-^     r       ^L 


Fig.  224. — Calculi  in  a  kidney  which  has  undergone  com- 
plete fatty-fibroid  degeneration. 


and  connective-tissue  formation  predominates  (Fig.  224);  the  hydro- 
nephrotic  calculous  kidney,  which  seldom  attains  a  large  size  and  is 
exceptionally  associated  with  diminution  in  size;  and  finally  the  lipoma  - 
tous  calculous  kidney,  in  which  the  atrophy  and  contraction  of  the 
parenchyma  is  accompanied  by  proliferation  of  the  fatty  tissue  pro- 
ceeding from  the  hilus. 

Entirely  different  from  any  of  these  forms  is  the  infected  calculous 
kidney,  in  which  there  is  a  suppurative  and  often  ulcerative  inflam- 


526 


DISEASES    OF    THE    KIDNEYS. 


mation  of  the  renal  pelvis  and  calices,  which  may  extend  to  the  medullary 
and  later  to  the  cortical  portion  of  the  kidney  and  give  rise  to  small 
foci  of  suppuration.  In  the  early  stages  of  this  condition  the  kidney 
is  usually  enlarged,  but  later  in  its  course,  owing  to  cicatricial  con- 
traction in  the  suppurating  tissue,  a  reduction  in  the  size  takes  place. 
(Fig.  225). 

If  in  consequence  of  obliteration  of  the  ureteral  opening,  obstruc- 
tion is  superimposed  upon  pyelitis  and  pyelonephritis,  a  pyonephrosis 
develops,  the  contents  of  which  are  pus,  blood,  and  primary,  secondary 
and  mixed  calculi.  The  pelvis  of  the  kidney  becomes  more  and  more 
distended  and  the  renal  parenchyma  is  destroyed  partly  by  liquefaction 


Fig.  225. — Pyonephrotic  kidney  containing  calculi, 
in  cavities,     b.  Spaces  filled  with  pus. 


a.  Calculi 


and  partly  by  pressure.  It  is  not  unusual  for  the  morbid  process  to 
break  through  the  kidney  and  invade  the  neighboring  tissues.  If 
this  occurs  gradually,  adhesions  form  between  the  fatty  and  fibrous 
capsule  and  the  superjacent  soft  parts,  producing  a  chronic  perineph- 


RENAL  AND  URETERAL  CALCULI.  527 

ritis  and  paranephritis,  whereas  if  the  extension  is  rapid  and  an  area 
of  suppuration  is  quickly  formed,  a  perinephric  or  paranephric  abscess 
is  the  result. 

In  regard  to  the  nature  of  the  infection,  it  may  be  stated  that  aseptic 
calculi  are  usually  infected  through  the  blood,  in  which  case  it  is  rare 
for  the  source  of  infection  to  be  determined.  It  may  also  occur  from 
below.  This  does  not  depend  alone  upon  the  transmission  of  infection 
by  instrumentation,  but  may  be  due  to  extension  of  gonorrhoea  or 
cystitis. 

Symptoms  and  Diagnosis.  Stone  in  the  kidney  presents  such  a 
variable  clinical  picture,  to  which  are  added  the  manifestations  of 
disease  in  other  organs,  that  the  establishment  of  a  positive  diagnosis 
may  be  attained  with  the  greatest  difficulty,  or  may  even  be  impossible. 

Moreover,  there  are  cases  in  which  calculi  may  be  present  in  the 
kidney  for  a  long  time  without  causing  any  symptoms,  although  this 
is  exceptional. 

The  passage  of  gravel  or  sand  usually  gives  rise  to  a  burning  or 
pricking  sensation  in  the  urethra,  which  is  due  to  the  irritation  pro- 
duced by  the  sharp  crystals  of  the  salts.  On  the  other  hand,  I  have 
frequently  seen  cases  in  which  large  bean-shaped  calculi  passed  along 
the  urinary  tract  to  the  external  urethral  orifice  without  causing  any 
pain  whatever. 

The  majority  of  cases,  however,  are  characterized  by  pain,  changes 
in  the  urine,  and  a  palpable  renal  tumor. 

The  pain  in  nephrolithiasis  may  be  either  constant  or  periodical. 
When  constant  it  occurs  as  a  feeling  of  pressure  in  the  region  of  the 
kidney,  which  annoys  the  patient  but  little  or  not  at  all,  although  it  is 
prone  to  become  worse  upon  motion,  and  particularly  upon  certain 
kinds  of  movement,  such  as  bending  or  stooping,  for  instance.  Pres- 
sure upon  the  kidney  or  upon  the  lumbar  region  below  the  last  rib 
also  increases  it. 

The  periodical  pain  occurs  in  the  form  of  renal  colic.  It  is  caused 
by  incarceration  of  a  stone  in  the  ureter  which  hinders  the  outflow  of 
urine,  and  also  by  the  contractions  which  the  ureteral  walls  make  in 
an  endeavor  to  expel  the  urine  in  the  pelvis  of  the  kidney  or  first  por- 
tion of  the  ureter. 

This  colic  is  usually  typical.  The  patient  writhes  with  pain,  becomes 
pale,  is  nauseated  or  vomits,  and  is  covered  with  sweat.  A  chill  may 
usher  in  the  attack.     The  pain  radiates  along  the  inguinal  region  down 


528  DISEASES   OF    THE    KIDNEYS. 

to  the  testicle  or  glans  penis ;  it  may  also  extend  upwards  to  the  thorax 
as  far  as  the  shoulder-blades. 

In  regard  to  the  urinary  changes,  deposits  of  the  salts  of  which  the 
calculi  are  composed  are  often  found;  if  pyelitis  is  present  pus  and 
epithelium  are  also  found.  All  of  these,  however,  may  be  absent. 
Only  one  substance  is  invariably  present,  and  that  is  blood.  Some- 
times it  can  be  plainly  seen  with  the  naked  eye,  and  with  the  microscope 
fresh  or  old  blood-corpuscles  never  fail  to  be  revealed.  There  is  only 
one  exception  to  this  rule,  namely,  when  the  passage  of  the  calculus 
is  completely  arrested  so  that  no  urine  can  escape.  It  must  be  borne 
in  mind,  however,  that  blood  may  appear  in  the  urine  in  other  renal 
diseases,  or,  indeed,  as  the  result  of  congestion  in  some  portion  of  the 
urinary  tract  other  than  the  kidney,  the  latter  being  perfectly 
healthy. 

A  total  occlusion  of  the  ureter  results  in  excretion  of  urine  from  the 
sound  kidney  only.  A  normal  urine,  therefore,  does  not  mean  that 
both  kidneys  are  healthy.  Occasionally  it  happens  that  both  kidneys 
are  stopped  up  with  calculi  at  the  same  time,  or  that  when  one  is 
obstructed  the  other  becomes  closed  through  reflex  spasm.  We  then 
have  to  do  with  anuria,  which,  unless  it  subsides  or  is  overcome  by 
artificial  means,  will  certainly  lead  to  uraemia  and  death. 

The  third  symptom  enumerated,  namely,  the  presence  of  a  palpable 
tumor,  is  very  untrustworthy;  in  many  cases  the  kidney  is  not  enlarged, 
in  others  the  abdominal  wall  is  too  thick  to  permit  accurate  palpation, 
and  finally  there  are  numerous  cases  in  which  the  kidney  is  placed  so 
deeply  under  the  ribs  that  it  itself,  much  less  a  calculus  within  it,  cannot 
be  felt.  If  a  hydronephrotic  or  pyonephrotic  calculous  kidney  has 
developed,  palpation  yields  the  results  mentioned  in  the  discussion  of 
those  maladies. 

In  addition  to  this  uncertainty  and  variability  of  symptoms  there 
is  another  circumstance  which  is  liable  to  increase  the  difficulty  of 
diagnosis,  namely,  that  the  affection  may  be  easily  confounded  with 
many  other  diseases. 

First  in  regard  to  renal  colic,  it  must  be  remembered  that  attacks 
having  exactly  the  same  characteristics  may  occur  in  the  absence  of 
calculi.  Gall  stones,  appendicitis  and  intestinal  obstruction  may 
cause  very  similar  attacks  of  pain.  A  floating  kidney  or  an  intermit- 
tent hydronephrosis  by  suddenly  causing  occlusion  of  the  ureter  may 
produce  a  true  colic.     Thick  blood-clots  in  renal  tumors,  plugs  of  pus 


RENAL  AND  URETERAL  CALCULI. 


529 


in  pyonephrosis  and  tuberculosis,  and  parasites  may  all  occasionally 
give  rise  to  colic  if  they  occlude  the  ureter. 

Moreover,  cases  have  been  observed  in  which  there  was  absolutely 
no  disease  of  the  kidney.  These  have  been  designated  as  nephralgia. 
There  are  also  cases  of  chronic  nephritis  in  which  exacerbations 
suddenly  occur  and  cause  typical  unilateral  renal  colic.  Finally  it 
must  not  be  forgotten  that  certain  gynecological  affections  (distorsion, 
adhesions  and  kinking  of  the  ureters  after  gynecological  operations) 
may  also  be  responsible  for  attacks  of  renal  colic. 

All  these  conditions  must  be  carefully  weighed  in  the  making  of  a 
diagnosis,  and  all  the  diagnostic  measures  which  we  possess  must  be 
employed.  The  history  of  the  case,  palpation,  and  examination  of 
the  urine  must  be  made  use  of.  Radiography  will  often  though  not 
always  be  of  help.  Catheterization  of  the  ureters  has  proved  itself 
to  be  the  most  valuable  aid  in  diagnosis.  From  cystoscopy  alone  not 
much  can  be  learned.  Inspection  of  the  ureteral  orifices  will  not 
show  whether  there  is  a  stone  in  the  ureter  unless,  as  very  rarely 
happens,  it  is  revealed  in  consequence  of  prolapse  of  the  mucosa  or  a 
large  gaping  ostium. 

On  the  contrary,  ureteral  catheterization  combined  with  functional 
examination  of  the  kidney  enables  us  to  differentiate  renal  colic  from 
gall  stones,  appendicitis  and  intestinal  obstruction.  In  these  affec- 
tions the  functional  capacity  of  both  kidneys  will  be  good  and  the 
value  of  A  and  sugar  approximately  the  same.  I  have  been  able  to 
diagnosticate  with  certainty  cases  of  this  kind  in  which  all  other 
methods  had  failed. 

In  nephrolithiasis,  particularly  in  cases  of  long  duration,  these 
values  will  also  be  lower  in  the  urine  from  the  diseased  kidney  than  in 
that  from  the  healthy  one.  If  the  kidney  is  otherwise  healthy,  however, 
the  differences  will  be  slight.     Examples: 

I.     LARGE      CALCULUS      WITH       PYONEPHROTIC       EIGHT      KIDNEY. 
CATHETERIZATION  OF  THE   URETERS    (PHLORIDZIN  O.Ol). 

Right  Left 

Urine:  Cloudy,  pus  moderate,  Clear,  no 

Albumen.  albumen. 
A          0.570  0.920 

Sugar:  0.3%  1.1 

36 


530  DISEASES    OF    THE    KIDNEYS. 

2.      ASEPTIC       CALCULOUS     KIDNEY     WITH    MEDIUM     SIZED     CALCULUS. 
CATHETERIZATION  OF  THE  URETERS  (PHLORIDZIN  O.Ol). 

Right  Left 

Urine:    Cloudy,     red     blood  Clear,  no 

corpuscles,    no     pus,  sediment, 

albumen    correspond-  no  albumen 
ing    to    the    amount 
of  blood. 

A         0.950  1.060 

Sugar:   0.8%  1.2% 

N. :        0.24  0.38 

In  large  hydronephroses  and  pyonephroses  the  difference  in  these 
values  is  much  greater  (see  under  these  diseases).  In  chronic  nephritis 
unequivocally  low  values  will  be  obtained  from  both  sides,  and  in 
nephralgia  the  functional  activity  of  both  kidneys  will  be  equally  good. 
The  certainty  of  diagnosis  under  these  difficult  conditions  has  been 
materially  advanced  by  ureteral  catheterization  and  functional  exam- 
ination of  the  kidneys. 

The  mistake  of  relying  solely  upon  these  methods  must  not  be 
made,  for  errors  may  occur.  Thus,  for  example,  a  chronic  nephritis 
associated  with  attacks  of  colic  may  be  so  mild  that  fairly  good  func- 
tional results  may  be  obtained  from  both  kidneys.  The  totality  of 
symptoms  must  be  considered  in  connection  with  the  findings  of  ure- 
teral catheterization  and  the  functional  examination,  in  order  for 
trustworthy  diagnostic  results  to  be  obtained. 

The  course  of  nephrolithiasis  is  chronic.  In  common  with  the 
prognosis  it  depends  largely  upon  treatment.  If  a  calculus  is  allowed 
to  remain  undisturbed,  it  may  in  exceptional  cases  be  expelled  spon- 
taneously through  the  natural  channels.  It  is  very  rare  for  a  stone 
to  break  through  the  kidney  and  give  rise  to  fatal  peritonitis.  Furth- 
ermore, spontaneous  cure,  in  the  sense  that  the  stone  permanently 
occludes  the  kidney  and  causes  gradual  pressure  atrophy  of  the  pa- 
renchyma to  the  point  of  complete  obliteration  without  producing 
infection,  is  also  rare.  The  supervention  of  complete  anuria,  which 
in  the  majority  of  cases  results  in  death  unless  intervention  is  prac- 
tised, is  also  unusual.  Most  frequently  the  kidney  becomes  infected 
in  the  course  of  time,  with  the  result  that  pyonephrosis  develops.    The 


RENAL  AND  URETERAL  CALCULI.  53 1 

earlier  nephrolithiasis  is  recognized  and  interference  practised  the  bet- 
ter will  be  the  prognosis. 

Treatment.  The  same  measures  recommended  for  the  prevention 
of  vesical  calculi  are  appropriate  in  the  prophylaxis  of  renal  stone. 
There  are  no  remedies  which  dissolve  calculi.  I  have  tested  those 
reputed  to  do  so,  namely,  lysidin,  urezidin,  lysetol,  urotropin,  urosin, 
chinotropin,  sidonal,  and  others  and  have  found  that  none  of  them 
possess  their  reputed  action.  The  most  that  can  be  done,  there- 
fore, is  to  guard  against  the  formation  of  new  calculi. 

In  this  respect  the  manner  of  living  is  first  to  be  considered.  The 
diet  of  persons  having  the  uric-acid  diathesis  should  not  be  rich.  An 
excess  of  meat  and  the  use  of  beer  are  to  be  avoided ;  foods  containing 
a  high  percentage  of  nuclein,  such  as  thymus,  spleen,  liver,  brains  and 
kidney  are  to  be  strictly  interdicted,  as  are  also  strong  tea  and  coffee. 
A  mixed  diet  consisting  of  a  moderate  amount  of  meat,  eggs,  and  an 
abundance  of  fruit  and  fresh  vegetables  is  to  be  recommended.  Suf- 
ficient exercise  and  warm  baths  should  be  taken  for  the  purpose  of 
securing  assimilation  and  elimination  of  the  food  ingested. 

In  order  to  increase  the  solvency  of  the  urine  for  uric  acid  it  is  well 
to  administer  alkalies  in  the  form  of  carbonates  and  vegetable  acid 
compounds,  alkaline  earths,  and  mineral  waters.  Lithium  citrate 
and  acetate  in  doses  of  0.1-0.2  [15-30  grains]  several  times  a  day, 
carbonate  of  lime,  borocitrate  of  magnesia  in  teaspoonful  doses,  or 
a  mixture  of  all  of  these  drugs,  may  be  used,  as  may  also  the  alka- 
line earthy  mineral  waters,  such  as  Wildungen,  Contrexeville,  Vichy, 
Offenbach,  Assmannshaus,  Bilin,  and  Neuenahr,  as  well  as  the  simple 
carbonated  waters  like  Apollinaris,  Harzer  Sauerbrunnen,  Elster,  and 
Franzensbad.  They  are  useful  not  only  because  of  their  alkaline 
action,  but  also  because  they  increase  diuresis,  with  the  result  that  a 
larger  quantity  of  uric  acid  can  be  held  in  solution. 

For  patients  of  less  means  the  artificial  Sandow  Salts  may  be  pre- 
scribed instead  of  the  natural  mineral  waters. 

The  diet  in  oxalate  calculi  is  practically  the  same,  although  food 
rich  in  lime  salts,  as  well  as  tea  and  a  few  vegetables  such  as  spinach 
and  sorrel,  which  are  rich  in  oxalic  acid,  must  be  avoided.  Some  caution 
must  be  employed  in  the  use  of  fruits.  Apples  are  contraindicated. 
The  simple  carbonated  waters  are  better  than  the  strongly  alkaline. 
Apollinaris,  Harzer  Sauerbrunn,  Krondorf,  and  Wernarz  in  Briick- 
enau  may  be  used. 


532  DISEASES    OF   THE    KIDNEYS. 

For  the  pressure-pains  of  nephrolithiasis  I  have  found  that  glycerine 
is  the  only  drug  except  the  narcotics  which  does  any  good.  It  was 
recommended  by  Hermann  in  doses  of  50  to  100  cc.  [approximately  i£ 
to  3  fl.  ounces].  I  have  given  as  much  as  150  cc.  [5  fl.  ounces]  twice  a 
week  and  have  been  well  pleased  with  the  results.  It  is  best  given 
with  20  cc.  [5  fl.  drachms]  of  syrup  of  orange  peel,  because  other- 
wise it  may  produce  nausea.  I  have  never  seen  any  ill  effects,  par- 
ticularly hsematuria,  follow  its  use,  although  slight  diarrhoea  is  some- 
times produced. 

Renal  colic  must  be  combated  by  means  of  hot  applications  to  the 
lumbar  region,  free  use  of  drinking  water  to  increase  diuresis,  and 
especially  by  the  administration  of  narcotics.  The  surest  remedy  to 
arrest  contractions  of  the  ureter  is  a  hypodermatic  injection  of  morphine. 
The  dose  must  be  full  and  commensurate  with  the  degree  of  tolerance 
which  the  patient  has  established.  If  vomiting  ensues  the  drug  may 
be  given  per  rectum  -with  a  small  glycerine  syringe. 

By  all  these  remedies  and  procedures  it  will  only  be  possible  to  cause 
the  expulsion  of  relatively  small  stones  in  fragments  or  in  their  entirety. 
Once  a  calculus  attains  a  size  larger  than  the  lumen  of  the  ureter  its 
spontaneous  expulsion  is  not  to  be  expected. 

Operative  treatment  then  has  to  be  considered.  Three  operations 
are  practised,  namely,  nephrolithotomy,  nephrotomy,  and  nephrectomy. 

In  nephrolithotomy  the  kidney  is  freed,  incised,  the  calculi  removed 
and  the  kidney  then  sutured.  In  nephrotomy,  after  the  stone  is  removed, 
the  kidney-wound  is  packed  with  gauze  and  left  open.  The  first 
operation  is  suitable  for  aseptic  calculous  kidneys,  the  second  for  those 
in  which  suppuration  is  present  in  the  pelvis  or  parenchyma  of  the 
kidney.  After  the  stone  has  been  removed  suppuration  of  the  open 
wound  continues  until  healing  and  cicatrization  gradually  occur.  If 
the  kidney  is  mostly  destroyed,  if  a  large  pyonephrotic  sac  is  present, 
or  if  the  remaining  kidney-tissue  is  highly  inflamed,  then  nephrec- 
tomy is  indicated. 

It  might  justly  be  asked  if  it  is  necessary  to  operate  on  every 
calculous  kidney. 

Cases  in  which  an  indication  is  manifestly  present  cannot  enter  the 
question.  If  the  attacks  of  colic  recur,  if  a  persistent  unbearable 
sensation  of  pressure  which  interferes  with  motion  exists,  if  the  haem- 
orrhage is  uncontrollable,  and  if  suppuration  is  present,  there  is  no 
doubt  that  an  operation  is  required.     Which  one  is  indicated  has  to 


TUMORS    OF    THE    KIDNEY. 


533 


be  determined  by  the  nature  of  the  case  and  the  condition  of  the  other 
kidney. 

Anuria,  unless  it  can  be  relieved  by  catheterizing  the  ureters,  also 
necessitates  immediate  surgical  intervention,  because  if  it  persists  it 
will  lead  to  uraemia  and  death.  Ureteral  catheterization  should  always 
be  attempted  before  operating.  I  once  succeeded  in  freeing  an  incar- 
cerated stone  by  injecting  oil  into  the  ureter.  In  another  case  due  to 
reflex  spasm  the  anuria  was  relieved  by  introducing  a  catheter  into  the 
unobstructed  ureter,  with  the  result  that  the  spasm  was  overcome 
and  the  flow  of  urine  established.  If  the  anuria  can  be  relieved  the 
prognosis  after  the  removal  of  the  stone  by  operation  is  much  better. 

Even  in  cases  in  which  none  of  these  urgent  indications  are  present 
I  believe  in  operating  whenever  the  presence  of  a  calculus  can  be 
positively  determined.  In  aseptic  calculous  kidney  the  danger  of 
operation  is  slight,  although  it  may  well  be  said  that  the  sword  of 
Damocles  hangs  over  the  patient's  head  if  his  malady  is  allowed  to  take 
its  course.  Anuria  develops  in  consequence  of  incarceration  of  a 
calculus,  or  the  renal  substance  is  destroyed  by  pressure,  or,  what  is 
more  frequent  than  either  of  these  conditions,  the  kidney  becomes 
infected,  pyelonephritis  or  pyonephrosis  develops  and  necessitates 
operation  later,  when  the  chances  of  cure  are  not  so  good  as  they  are 
in  uncomplicated  aseptic  nephrolithiasis. 

TUMORS  OF  THE  KIDNEY. 

The  most  common  as  well  as  the  most  interesting  of  renal  tumors 
are  hypernephroma,  carcinoma  and  sarcoma.  Concerning  the  causes 
of  carcinoma  and  sarcoma  nothing  is  known.  Hypernephroma,  also 
called  epinephroid,  struma  suprarenalis,  and  Grawitz's  tumor, 
originates  from  misplaced  elements  of  renal  tissue.  (Plate  XXIII.) 
Primary  tumors  only  will  be  considered  here,  as  those  of  metastatic 
origin  are  not  subject  to  treatment.  In  contradistinction  to  metas- 
tatic growths,  which  usually  affect  both  kidneys,  primary  cancer  and 
sarcoma  are  almost  always  unilateral.  Cancer  is  more  common  than 
sarcoma.  Both  may  occur  at  any  time  of  life,  although  they  are  most 
common  after  fifty. 

Pathological  Anatomy.  [The  hypernephromata  are  sharply 
defined  from  the  surrounding  tissue,  being  enclosed  in  a  capsule 
derived  originally  from  the  renal  tissue  itself,  which  undergoes  atrophy. 
The  tumor  substance  is  usually  yellow  in  color,  owing  to  its  abundant 


534 


DISEASES    OF    THE    KIDNEYS. 


fat  content,  although  Steorck  believes  it  to  be  due  to  the  presence  of 
protagon  instead  of  fat. 

Microscopic  examination  shows  that  these  tumors  have  a  glandular 
structure.     Muscle  fibers  and  giant-cells  have  been  found  in  them. 

Hypernephromata  may  undergo  cystic,  carcinomatous  or  sarcom- 
atous degeneration.] 

The  majority  of  renal  carcinomata  are  of  the  soft  medullary  variety, 
which  may  attain  a  considerable  size.  The  rarer  hard  scirrhus  cancer 
is  nodular  and  is  not  so  large  (Fig.  226).  The  tumor  is  usually 
kidney-shaped,  has  either  a  smooth  or  rough  surface,  and  sometimes 

extends  into  the  pelvis  of  the  kidney  or 
even  into  the  ureter.  Thrombosis  of 
the  renal  vein  or  inferior  vena  cava 
may  occur.  In  the  substance-  of  the 
tumor  areas  of  softening  and  haemor- 
rhage are  found.  Metastases  are  com- 
paratively rare.  Cancer  may  extend  to 
the  neighboring  parts,  to  the  perito- 
neum, intestine  or  liver.  The  retro- 
peritoneal lymph  glands  are  involved 
the  earliest. 

While  carcinoma  originates  from  the 
epithelium  of  the  uriniferous  tubules, 
sarcoma,  both  spindle  and  round-cell, 
develops  from  the  capsule  of  the  kidney 
or  the  perirenal  connective  tissue.  Small 
round-cell  sarcoma  is  more  malignant 
than  the  large-cell  variety,  although  even 
in  the  former  metastases  occur  comparatively  late  in  the  disease. 

Symptoms  and  Diagnosis.  The  symptoms  of  tumor  of  the  kidney 
are  pain  over  the  affected  side,  changes  in  the  urine,  cachexia,  the 
formation  of  a  mass,  and  pain  in  other  parts  of  the  body  when 
metastases  occur.  Unfortunately  these  symptoms  are  seldom  present 
together.  As  a  rule,  the  majority  of  them  are  absent,  or  they  are  first 
noticed  when  it  has  become  too  late  for  operative  interference. 

First,  as  regards  the  pain  in  the  lumbar  region,  no  reliance  whatever 
is  to  be  placed  upon  it.  Although  it  is  sometimes  present  I  have  more 
often  found  that  it  was  absent,  the  patient  even  not  having  experienced 
the  slightest  sensation  of  discomfort  in  the  diseased  part. 


Fig.   226. — Scirrhus  carcinoma  of 
the  kidney. 


PLATK    XXIII 


\ 


LARGE  HYPERNEPHROMA,        (DRAWING  FROM  A   SPECIMEN   REMO\  I 
MR.   C.   H.  GOLDING-B1RD,  OF  LONDON.) 


TUMORS    OF    THE    KIDNEY. 


535 


The  only  change  in  the  urine  which  is  of  any  importance  is  the 
presence  of  blood.  Pus-corpuscles  are  of  no  significance,  as  their 
presence  always  depends  upon  secondary  changes.  There  is  a  double 
reason  why  the  possible  presence  of  tumor-cells  is  not  to  be  depended 
upon.  In  the  first  place  the  normal  epithelium  of  the  urinary  tract 
may  closely  resemble  these  cells  and,  secondly,  the  latter  are  very  rarely 
found  in  the  urine.  Albumen  is  of  no  importance  as  it  is  due  to  second- 
ary causes.     Casts  are  merely  the  expression  of  a  coexistent  nephritis. 

Haematuria  may  be  very  severe  or  so  slight  as  to  be  detected  only  by 
the  microscope.  It  must  of  course  be  determined  that  the  source  of 
the  blood  is  from  the  kidney.  This  is  nearly  always  possible  by  means 
of  cystoscopy  and  catheterization  of  the  ureters.  It  is  no  longer 
necessary  to  depend  upon  the  highly  untrustworthy  means  of  differ- 
entiation formerly  in  vogue,  namely,  whether  the  blood  is  red  or  brown, 
whether  the  corpuscles  are  old  or  fresh,  and  whether  the  blood  occurs 
in  the  form  of  worm-like  masses.  These  phenomena  are  of  value 
when  present,  but  they  are  frequently  absent.  It  must  be  remembered, 
however,  that  the  bleeding  kidney  might  not  be  the  one  in  which  the 
tumor  is  situated,  as  the  other  one  might  bleed  owing  to  congestion 
or  the  presence  of  calculi.  Such  a  condition  must  of  course  be  exceed- 
ingly rare. 

Much  has  been  written  concerning  the  kind  of  haemorrhage  character- 
istic of  renal  tumors.  It  is  true  that  the  haemorrhage  is  usually  profuse 
and  of  long  duration,  that  it  occurs  suddenly  and  ceases  in  the  same 
manner,  and  that  it  is  not  influenced  by  treatment.  All  this,  however, 
may  occur  in  vesical  tumors  without  producing  tenesmus.  Therefore 
such  bleeding  cannot  be  considered  a  means  of  differential  diagnosis. 

There  is  yet  a  greater  difficulty  than  this.  A  tumor  may  exist  for 
years  before  it  causes  haemorrhage  even  though  in  many  cases 
bleeding  is  an  early  symptom.  So,  too,  years  may  elapse  between  the 
first  and  second  haemorrhage. 

A  more  constant  symptom  is  cachexia.  I  have  observed  that 
nearly  all  patients  having  renal  tumor  enter  upon  a  decline,  become 
markedly  emaciated,  and  upon  first  sight  give  one  the  impression 
that  they  are  seriously  ill.  It  would  be  more  important,  of  course,  to 
recognize  the  disease  before  cachexia  developed.  Its  presence  may  well 
cause  fear  that  the  disease  is  'far  advanced. 

The  most  positive  sign,  the  presence  of  a  tumor,  is  one  of  the  most 
importance,  as  it  is  less  commonly  absent  than  the  others.     Upon 


536  DISEASES    OF    THE    KIDNEYS. 

palpation  a  mass  may  be  felt  under  the  costal  arch  when  the  patient 
breathes  deeply;  it  can  often  be  learned  whether  the  growth  is  smooth 
or  rough,  how  large  it  is,  and  whether  it  is  distinct  from  the  kidney. 

Of  course  it  is  not  always  easy  to  tell  whether  a  tumor  thus  palpated 
is  in  the  kidney;  confusion  with  other  organs,  such  as  the  liver,  gall- 
bladder, intestines,  spleen,  ovaries,  uterus  and  enlarged  retroperi- 
toneal lymph-glands,  has  occurred.  Moreover,  there  are  tumors  which 
produce  only  small  nodules,  are  placed  deep  in  the  kidney,  and  there- 
fore cannot  be  felt,  and  others  which  together  with  the  kidney  are 
so  concealed  under  the  costal  arch  that  they  are  not  accessible  to 
palpation.  Finally  it  must  be  stated  that  the  disease  is  usually  well 
advanced  before  the  tumor  can  be  plainly  felt. 

It  is  the  same  with  the  "  rheumatoid  pains"  which  are  felt  in  different 
parts  of  the  body  and  which  are  to  be  attributed  to  metastases  in  the 
bones.  If  they  prove  to  be  caused  by  metastases  diagnosis  is  then  of 
no  practical  value.  Other  metastases,  for  example,  glandular  involve- 
ment, make  it  difficult,  particularly  at  first,  to  establish  a  diagnosis. 

From  this  sketch  of  the  symptom-complex  it  is  seen  that  malignant 
tumors  of  the  kidney  are  not  difficult  to  diagnosticate  at  a  certain 
period  of  their  evolution,  and,  moreover,  that  an  early  diagnosis 
is  of  the  utmost  importance. 

Therefore  the  greatest  attention  must  be  given  to  ever}'  urinary 
haemorrhage.  Reliance  must  not  be  placed  on  the  fact  that  haemor- 
rhage may  occur  from  a  healthy  kidney,  but  every  renal  haemorrhage 
must  be  most  carefully  investigated.  Every  patient  should  be  imme- 
diately subjected  to  catheterization  of  the  ureters  and  functional 
examination  of  the  kidneys.  The  functional  capacity  of  a  kidney  in 
which  the  normal  tissue  has  been  replaced  by  the  elements  of  a  new 
growth  is  always  lower  than  that  of  the  other  kidney,  and  this  is  true 
in  a  stage  of  the  disease  when  all  other  symptoms  and  signs  may  be 
absent.     An  example  may  illustrate  this  fact. 

Case  L  (operation). 

CATHETERIZATION  OF  THE  URETER   (o.OI    PHLORIDZIN). 

Right.  Left. 

Urine:  Clear,  only  a  Clear,  free  from 

few  erythrocytes,  all  abnormal 

no  albumen.  elements. 

A           0.21  0.45 

Sugar:    0.4  1.0 


TUMORS    OF    THE    KIDNEY.  537 

In  this  case  the  examination  was  made  in  the  interval  of  freedom 
from  haemorrhage  and  other  symptoms.  The  patient  had  a  haem- 
orrhage weeks  before.  A  diagnosis  of  tumor  of  the  right  kidney  was 
at  once  made,  and  it  was  confirmed  by  the  operation.  This  case  shows 
the  importance  of  the  examination.  Without  the  functional  test 
one  would  have  been  obliged  to  wait  until  another  haemorrhage  had 
occurred  in  order  to  determine  the  source  of  the  bleeding,  as  there  was 
no  palpable  tumor,  and  other  symptoms,  such  as  marked  emaciation, 
were  entirely  absent. 

Therefore,  in  the  early  diagnosis  of  malignant  tumors  of  the 
kidney,  the  functional  renal  examination  is  very  valuable, 
although  it  must  be  remembered  that  care  is  necessary  in  forming  a 
conclusion,  inasmuch  as  in  tumors  of  the  renal  capsule  and  suprarenal 
gland,  which  may  give  rise  to  the  same  symptoms  as  renal  tumors, 
although  the  substance  of  the  kidney  is  only  slightly  or  not  at  all  attacked, 
the  functional  examination  may  yield  the  same  or  approximate  results. 

From  this  the  following  conclusion  is  to  be  drawn:  if  a  mass  can  be 
felt  on  one  side  or  a  haemorrhage  from  the  kidney  on  this  side  be  deter- 
mined, and  if  the  values  for  A  and  sugar  in  the  urine  from  this  kidney 
are  considerably  lower  than  in  that  from  the  opposite  one,  then  a  tumor 
of  the  kidney  certainly  exists,  provided  that  the  symptoms  present 
are  such  as  occur  in  tumor  and  not  in  other  affections,  as  tuberculosis, 
for  instance;  if  a  mass  can  be  felt  and  the  values  are  high,  tumor 
cannot  be  excluded,  for  one  of  the  above  mentioned  forms  may  be 
present. 

In  comparison  with  the  great  advantages  which  this  examination 
offers,  the  other  signs,  although  they  should  never  be  disregarded,  are 
of  minor  importance.  According  to  Guyon  the  sudden  development 
of  a  varicocele  upon  the  diseased  side  should  arouse  suspicion  of  a 
renal  tumor.  This  may  be  true,  but  there  are  tumors  enough  in  which 
varicocele  is  absent. 

Concerning  benign  tumors  of  the  kidney,  which  are  very  rare,  and 
of  which  adenoma,  fibroma  and  lipoma  are  by  far  the  most  common, 
it  may  be  said  that  they  are  considerably  smaller  than  malignant 
growths,  that  they  increase  in  size  less  rapidly,  and  that  cachexia  does 
not  occur.     It  is  very  difficult  to  diagnosticate  them  during  life. 

The  prognosis  of  malignant  tumors  is  bad — bad  without  operation 
and  bad  with  operation.  In  the  minority  of  cases  death  results  directly 
from  the  operation;  in  the  majority,  however,  it  is  due  to  metastases. 


53^  DISEASES    OF   THE    KIDNEYS. 

The  earlier  the  diagnosis  the  better  the  prognosis  as  regards  both 
immediate  and  remote  results. 

As  to  treatment,  nephrectomy  is  the  only  procedure  to  be  considered. 
Operation  is  indicated  when  the  functional  capacity  of  the  other  kidney 
is  good  and  the  general  condition,  particular^  the  cardiac  action,  leads 
one  to  believe  that  metastases  have  not  occurred. 

Stress  should  be  laid  upon  the  fact  that  the  previously  mentioned 
capsular  tumors  (of  which  the  fibroma  and  sarcoma  generally  origi- 
nate in  the  fibrous,  and  lipoma  and  myxosarcoma  in  the  fatty  capsule), 
may  attain  large  dimensions,  and  that  they  are  characterized  by  their 
retroperitoneal  location,  displacement  of  the  colon,  slight  mobility, 
and  absence  of  urinary  haemorrhage. 

Great  caution  must  be  employed  in  basing  a  diagnosis  upon  displace- 
ment of  the  colon,  because  the  colon  may  push  a  renal  tumor  upwards, 
or  a  tumor  may  displace  the  colon  lateralwards.  I  have  often  seen 
both  these  conditions.  These  tumors  of  the  capsule  are  therefore 
very  difficult  to  diagnosticate.  Treatment  consists  in  their  removal, 
which  necessitates  the  sacrifice  of  the  kidney. 

TUMORS  OF  THE  PELVIS  OF  THE  KIDNEY 
AND  URETER. 

Tumors  of  the  renal  pelvis  and  ureter  are  exceedingly  rare.  There 
are  two  kinds,  both  of  which  have  a  papillary  structure;  one  is  true 
papillary  carcinoma,  the  other  simple  papilloma,  such  as  often 
occurs  in  the  bladder.  The  latter  form  cannot  be  considered  as 
strictly  benign  because  it  often  extends  into  the  ureter  and  bladder. 
Although  its  structure  may  appear  benign  under  the  microscope  its 
multiplicity  makes  it  of  a  severe  and  serious  nature. 

The  recognition  of  this  affection  is  beset  with  great  difficulties. 
Little  can  be  learned  by  palpation,  for  the  tumors  are  small  and  do  not 
cause  enlargement  of  the  kidney.  If  the  kidney  becomes  enlarged 
it  is  generally  owing  to  obstruction  of  the  renal  pelvis  by  the  tumor. 
The  mass  then  has  the  characteristics  of  hydronephrosis. 

From  the  latter,  however,  the  affection  may  be  distinguished  by  a 
marked  tendency  to  haemorrhage,  which  does  not  exist  in  hydroneph- 
rosis. 

James  Israel  has  called  attention  to  an  important  symptom.  He 
has  noticed  that  in  consequence  of  the  great  vascularity  of  the  tumor, 
its  size  varies  with  the  degree  of  distention  of  its  blood  vessels.     If 


CYSTS    OF    THE    KIDNEY. 


539 


haemorrhage  occurs  the  tumor  becomes  smaller,  as  does  also  the 
engorged,  enlarged  kidney,  which  remains  small  until  another  attack 
of  congestion  and  interference  with  the  outflow  of  urine  causes  it  to 
enlarge  again.  As  Israel  has  aptly  said,  the  clinical  picture  is  one  of 
intermittent  haematonephrosis.  Rarely  fragments  of  the  tumor 
may  be  found  in  the  urine;  their  source  can  be  determined  by 
cystoscopy. 

Up  to  the  present  time,  owing  to  the  rarity  of  the  disease,  functional 
examination  has  been  made  in  only  one  case.  In  this  one  there  was 
a  great  difference  in  the  urine  of  the  two  kidneys,  a  circumstance  which 
was  due  to  the  fact  that  the  kidney  was  also  affected  with  interstitial 
inflammation.  In  absence  of  such  inflammation  there  is  no  reason 
why  the  function  of  the  kidney  should  be  materially  impaired.  The 
values  for  both  sides  should  be  good  and  practically  the  same- 
Treatment  consists  in  complete  extirpation  of  the  kidney,  together 
with  removal  of  as  much  of  the  ureter  as  is  possible,  because,  as  has 
already  been  stated,  the  tumor  frequently  invades  the  ureter. 

CYSTS  OF  THE  KIDNEY  (BENIGN  CYSTS  AND 
POLYCYSTIC  DEGENERATION). 

Small  multiple  cysts  are  found  in  perfectly  healthy  kidneys,  especially 
in  the  cortex.  They  are  of  no  practical  importance,  being  due,  no 
doubt,  to  constriction  of  the  uriniferous  tubules. 

Small  and  large  cysts  are  also  found  in  genuine  contracted  and 
arteriosclerotic  contracted  kidney,  in  which  the  constricting,  contracting 
connective  tissue  has  caused  occlusion  of  the  uriniferous  tubules. 

Unless  they  attain  considerable  size  they  are  likewise  of  no  practical 
importance. 

In  contradistinction  to  these,  that  rare  condition  known  as  cystic 
degeneration  of  the  kidney,  which  develops  in  both  organs 
simultaneously,  is  fraught  with  special  interest.  Either  massive 
cysts  or  a  number  of  sacs  separated  by  remnants  of  parenchyma  are 
found  in  the  kidney,  which  is  much  enlarged  owing  to  their  presence. 
(Rein  gros  polycystique  of  the  French).  (Fig.  227.) 

Their  surface  is  bosselated,  their  contents  composed  of  serum,  mucus 
and  blood.  The  congenital  forms  will  not  be  considered  here  as  they 
are  of  no  importance  except  that  they  constitute  a  hindrance  to  birth. 
They  are  due  to  constriction  of  the  uriniferous  tubules,  to  atresia  of  the 


54o 


DISEASES    OF    THE    KIDNEYS. 


papillae  occurring  in  intrauterine  life,  and  to  dilatation  of  Miiller's 
capsule  following  haemorrhage. 

Of  practical  importance  is  polycystic  degeneration  occurring  at  a 
later  age,  which  is  due  to  abnormalities  that  originate  during  fcetal  life, 
although  they  manifest  themselves  at  a  later  period  of  existence. 
(Victor  Steiner  believes  that  the  condition  is  hereditary.) 

The  diagnosis  of  this  condition  is  uncommonly  difficult.  The 
cysts  often  remain  entirely  latent,  are  frequently  not  palpable,  and  when 


Fig.  227. — Cystoma  of  the  kidney.     Removed  from  an  adult.     (Kiister.) 


they  can  be  felt  are  very  difficult  to  distinguish  from  other  renal  tumors. 
Their  bosselated  surface  may  cause  them  to  be  mistaken  for  malignant 
tumors,  although  this  attribute  serves  to  distinguish  them  from  the 
hydronephrotic  kidney,  which  has  a  smooth  surface.  The  most  impor- 
tant characteristic  is  that  they  occur  bilaterally.  If  a  mass  which  is 
apparently  cystic  is  felt  on  both  sides  this  disease  must  be  thought  of. 
Naturally,  under  certain  conditions,  a  palpable  mass  may  be  found 
on  one  side  only,  and  then  this  sign  fails. 


MOVABLE    KIDNEY. 


541 


Another  important  diagnostic  sign  is  the  frequent  simultaneous 
occurrence  of  hepatic  cysts.  The  latter  also  often  escape  detection. 
Changes  in  the  urine  are  likewise  unconstant ;  they  may  be  present  or 
absent.  The  urine  is  similar  to  that  of  contracted  kidney,  being  very 
pale,  of  low  specific  gravity  and  very  copious  in  quantity.  In  both  affec- 
tions there  is  destruction  of  renal  tissue.  Israel  also  found  the  circu- 
latory changes  characteristic  of  contracted  kidney,  namely,  increase  in 
arterial  tension  and  hypertrophy  and  dilatation  of  the  left  ventricle. 

Functional  examination  of  the  kidney  will  afford  the  best  means  of 
diagnosis,  for  the  reason  that  diminution  in  the  functional  power  of 
the  organ  is  bound  to  be  expressed  by  figures,  although  as  yet  the 
examination  has  not  been  made. 

It  is  remarkable  how  long  persons  affected  with  the  malady  may 
live  without  experiencing  any  difficulty.  It  shows  with  how  little 
renal  tissue  a  patient  may  live,  as  long  as  the  transient  equilibrium  of  the 
organism  remains  and  is  not  disturbed  by  surgical  interference. 
Therefore,  the  diagnosis  of  this  condition  is  most  important,  because  it 
will  prevent  interference  which  will  destroy  the  patient.  As  the  affec- 
tion is  bilateral  operative  treatment  is  out  of  the  question. 

MOVABLE  KIDNEY  (REN  MOBILIS  SEU  MIGRANS). 

A  movable  kidney  is  one  which  is  abnormally  situated  and  unduly 
mobile.  The  degree  of  mobility  is  variable;  in  some  cases  the  kidney 
may  be  displaced  only  a  short  distance,  while  in  others  it  may  be  freely 
moved  upward  under  the  costal  arch  or  downward  apparently  as  far 
as  the  small  pelvis.  A  kidney  which  is  deeply  situated  and  easily 
palpable,  but  not  mobile,  is  not  to  be  considered  as  a  movable  kidney. 

Movable  kidney  may  be  congenital,  although  it  is  more  frequently 
acquired.  It  is  more  common  on  the  right  side  than  on  the  left,  and 
affects  women  oftener  than  men.  Its  development  is  due  to  loosening 
of  the  attachments  of  the  kidney  (Landau),  which  may  be  caused  by 
pressure  of  tumors  in  neighboring  organs  or  by  growths  in  the  kidney 
itself  which  make  traction  upon  the  attachments;  by  traumatisms 
sustained  during  violent  fits  of  coughing,  severe  straining  at  stool, 
heavy  lifting,  etc. ;  by  severe  diseases  which  lead  to  rapid  shrinking  of 
the  paranephric  fatty  tissue ;  by  relaxation  of  the  pelvic  organs,  such  as 
occurs  in  the  puerperium  when  involution  of  the  genital  organs  takes 
place;  by  tight  lacing  which  produces  dislocation  of  the  liver  and 
consequent   pressure   upon  the   right   kidney;   and   possibly   also  by 


542  DISEASES    OF    THE    KIDNEYS. 

frequently  repeated  congestion  of  the  renal  plexus  produced  by  the 
afflux  of  blood  to  the  communicating  ovarian  plexus  during  menstrua- 
tion. Occasionally  movable  kidney  is  only  a  part  of  a  general  enterop- 
tosis. 

In  consequence  of  inflammatory  adhesions  a  movable  kidney  may 
become  firmly  fixed  in  an  abnormal  position.  As  a  rule,  the  paren- 
chyma of  the  organ  is  perfectly  healthy,  although  other  affections  such  as 
cystic  degeneration  and  pyonephrosis  may  occur.  An  associated 
hydronephrosis  is  exceedingly  common,  the  mobility  of  the  kidney 
causing  the  ureter  or  outlet  of  the  renal  pelvis  to  become  compressed, 
thus  producing  a  retention  of  fluid. 

Symptoms  and  Diagnosis.  In  a  large  number  of  cases  movable 
kidney  does  not  give  rise  to  any  symptoms.  In  a  minority  of  cases 
symptoms  are  present,  although  it  is  doubtful  whether  they  all  depend 
upon  the  movable  kidney  or  whether  they  are  not  due  rather  to  the 
condition  produced  by  general  enteroptosis. 

The  most  pronounced  symptoms  are  a  series  of  severe  nervous 
disturbances  caused  by  pressure  and  traction  upon  the  nerves  of  the 
kidney.  Neuralgic  pains  radiate  to  the  sacrum,  back  and  groin. 
They  are  more  acute  during  menstruation  and  are  also  increased  by 
bodily  exertion  and  violent  exercise.  Digestive  disturbances  are  also 
marked ;  they  consist  in  anorexia,  nausea,  vomiting,  constipation,  and 
distention  of  the  abdomen.  Nervous  palpitation  of  the  heart  has  also 
often  been  observed. 

Disturbances  of  micturition  may  be  present,  although  in  the  majority 
of  cases  the  urine  is  normal  as  to  quantity  and  quality.  When  altera- 
tions occur  they  are  the  same  as  those  of  intermittent  hydronephrosis. 

The  occasional  occurrence  of  renal  colic  in  hydronephrosis  has 
already  been  mentioned.  Even  without  the  supervention  of  hydro- 
nephrosis, movable  kidney  may  sometimes  give  rise  to  typical  colic 
owing  to  a  sort  of  strangulation  and  closure  of  the  kidney  produced 
by  its  abnormal  position,  torsion  and  kinking  of  the  vessels,  and 
occlusion  of  the  ureter.  The  attacks  of  colic  thus  produced  differ  in  no 
wise  from  those  previously  described  as  occurring  in  nephrolithiasis. 

The  diagnosis  of  movable  kidney  can  be  positively  made  by  pal- 
pation, which  is  easily  performed  by  the  bimanual  method,  and 
which  reveals  an  abnormally  mobile  and  dislocated  kidney  and 
enables  the  examiner  to  recognize  its  typical  form  and  consistency. 
Pressure  over  the  kidney  usually  fails  to  elicit  pain.     Percussion  gives 


MOVABLE    KIDNEY.  543 

forth  a  dull  note,  but  upon  inflation  of  the  colon  the  dullness  gener- 
ally disappears. 

The  prognosis  of  movable  kidney  is  favorable.  As  a  rule,  the 
condition  persists  for  years  unless  intervention  is  practised;  in  a  few 
cases  infection  of  the  kidney  takes  place  in  consequence  of  the  circula- 
tory disturbances  and  intermittent  distention  of  the  renal  pelvis 
with  urine.  Cases  of  spontaneous  cure  have  been  observed,  particu- 
larly in  persons  who  have  taken  on  flesh  rapidly,  and  it  has  been  endeav- 
ored to  produce  this  condition  artificially  by  means  of  Weir  Mitchell's 
rest-cure. 

Treatment.  First  of  all  our  attention  must  be  directed  to  the 
prevention  of  movable  kidney.  For  this  purpose  a  strict  veto  must  be 
placed  upon  tight  lacing  and  great  care  employed  in  the  hygiene  of  the 
puerperium.  Puerperal  women  should  not  be  allowed  to  get  up  too 
soon,  and  should  wear  a  wide  abdominal  binder,  which  acts  as  a  support 
to  the  pelvic  organs  during  involution. 

If  a  movable  kidney  causes  trouble  it  should  first  be  treated  by  means 
of  bandages,  of  which  there  are  many  serviceable  kinds.  Good 
results  are  sometimes  obtained  in  the  case  of  emaciated  persons  by  a 
rest-cure,  from  which  it  may  be  assumed  that  absorption  of  fat  caused 
the  development  of  the  movable  kidney. 

If  these  measures  do  not  afford  relief  and  severe  symptoms  arise 
which  make  the  patient's  life  miserable,  nephropexy  should  be 
resorted  to;  as  it  is  now  performed  it  is  without  danger  and  offers  a 
certain  cure.  I  have  completely  abandoned  suture  of  the  kidney, 
fixation  to  the  ribs,  etc.,  and  now  do  merely  a  decapsulation. 

The  capsule  of  the  kidney  is  split  on  the  convex  border  of  the  organ 
from  one  pole  to  the  other,  stripped  off  on  each  side,  and  then  cut 
completely  away  near  the  pelvis.  The  kidney  thus  bared  is  replaced 
upon  the  fatty  capsule,  which  is  fastened  as  high  as  possible  to  the 
underlying  muscle  with  a  few  strong  catgut  sutures.  Firm  adhesions 
then  form  between  the  fatty  capsule  and  the  muscle  on  one  side  and 
the  kidney  and  fatty  capsule  on  the  other.  This  operation  is  devoid 
of  the  dangers  incident  to  the  earlier  operations  in  which  sutures 
were  passed  through  the  substance  of  the  kidney,  and  I  have  found  it 
thoroughly  reliable  in  a  series  of  cases. 

If  there  is  a  complicating  hydronephrosis,  together  with  frequent 
attacks  of  renal  colic,  treatment  is  to  be  conducted  in  accordance 
with  the  rules  prescribed  for  the  management  of  that  affection. 


544  DISEASES    OF    THE    KIDNEYS. 

PARASITES  IN  THE  KIDNEY. 

The    Echinococcus. 

The  echinococcus,  the  embryo  of  tania  echinococcus,  which  inhabits 
the  intestine  of  the  dog,  is  found  in  the  kidney,  as  in  other  organs,  in  the 
form  of  a  large  round  or  ovoid  gelatinous  cyst  containing  a  clear  watery 
fluid  in  which  numbers  of  daughter- cysts  are  floating.  On  the  inner 
wall  of  the  smallest  cyst  scolices  are  found  having  a  rostellum  provided 
with  hooklets,  which  are  important,  as  they  also  float  free  in  the  fluid 
and  thus  contribute  to  the  recognition  of  the  disease. 

If  the  ovum  of  the  taenia  echinococcus  gains  access  to  the  stomach  of 
man,  it  is  freed  from  its  investing  membrane  and  enters  the  blood- 
vessels of  the  intestine,  whence  it  passes  into  the  portal  vein  and 
thence  direct,  or  perhaps  through  the  lymph-channels,  into  the  right 
side  of  the  heart.  From  the  heart  it  is  carried  by  the  arterial  blood- 
current  to  different  organs  of  the  body,  particularly  the  liver  and  kidneys. 

The  kidneys  are  attacked  much  more  frequently  than  the  liver,  and, 
as  a  rule,  only  one  kidney  is  affected.  The  echinococcus  works  its 
way  from  the  cortex  to  the  pelvis  of  the  kidney.  The  cyst  becomes 
adherent  to  other  organs  (spleen,  liver)  and  may  rupture  into  them; 
simultaneous  rupture  into  the  bronchi  and  renal  pelvis  has  been 
observed. 

The  disease  first  becomes  recognizable  when  it  leads  to  the  forma- 
tion of  a  renal  tumor.  This  mass  occupies  the  position  of  the  kidney, 
may  be  very  large  and  even  reach  to  the  brim  of  the  pelvis.  It  has  the 
characteristics  of  a  renal  tumor,  fluctuates,  and  occasionally  gives  forth 
the  so-called  hydatid  thrill,  although  the  latter  sign  is  not  of  much 
value  because  it  may  occur  in  simple  hydronephrosis.  It  may  be 
very  difficult  to  elicit  fluctuation,  and  also  to  determine  whether  the 
tumor  is  in  relation  with  the  kidney.  The  difficulties  which  obtain  in 
the  diagnosis  of  renal  tumors  have  been  repeatedly  described. 

The  affection  becomes  easily  recognizable  if  the  contents  of  the  cyst 
rupture  into  the  pelvis  of  the  kidney.  Before  this  happens  the  urine 
may  be  absolutely  normal.  If  blood  or  pus  are  present  they  are  due 
to  secondary  changes.  When  rupture  occurs,  however,  the  vesicles 
reach  the  pelvis  of  the  kidney  and  bladder  and  are  voided  with  the 
urine.  Diagnosis  is  then  readily  made  by  finding  the  vesicles  and 
characteristic  hooklets.  The  urine  then  also  usually  contains  pus  and 
albumen. 


PARASITES    IN    THE    KIDNEY. 


545 


The  discharge  of  the  cyst  through  the  ureter  may  be  accompanied 
by  colicky  pains  owing  to  temporary  though  complete  occlusion 
of  the  ureter  by  the  large  vesicles. 

Vesical  tenesmus  and  strangury  have  also  been  observed  when  a 
large  number  of  cysts  were  passed  or  when  they  occluded  the  outlet 
of  the  bladder.     As  a  rule,  however,  their  passage  causes  no  trouble. 

It  is  important  to  remember  that  the  presence  of  cchinococcus  cysts 
in  the  urine  does  not  mean  that  they  come  from  the  kidney,  for  the 
location  of  the  primary  cyst  may  have  been  the  liver,  from  which  it 
perforated  the  renal  pelvis,  or  a  cyst  between  the  rectum  and  bladder 
may  have  broken  into  the  latter  vise  us. 

The  prognosis  is  generally  favorable.  The  disease  may  last  for 
years  without  giving  rise  to  any  trouble.  Rupture  of  an  echinococcus 
cyst  into  the  lung  may  prove  fatal;  its  rupture  into  the  pelvis  of  the 
kidney,  however,  constitutes  a  natural  method  of  cure.  It  is  evident 
that  the  parenchyma  of  the  kidney  will  suffer  pressure-atrophy,  and 
that  it  may  be  completely  destroyed  if  sufficient  distention  of  the 
sac  takes  place. 

Treatment.  As  soon  as  the  disease  has  been  positively  recognized 
operation  is  indicated.  Exploratory  puncture  and  the  finding  of 
vesicles  and  hooklets  will  make  diagnosis  positive.  The  kidney  should 
then  be  laid  freely  open,  its  contents  evacuated,  and  the  sac  cleansed 
and  drained.  Nephrectomy  is  permissible  only  when  practically  no 
renal  tissue  remains.  Kiimmel  succeeded  in  resecting  the  diseased 
portion  of  the  kidney  and  leaving  the  healthy  part  intact. 

Of  the  remaining  animal  parasites  found  in  the  kidney  the 
eustrongylus  gigas,  the  distoma  haematobium  and  filaria  sanguinis  are 
of  some  importance. 

The  eustrongylus  gigas,  a  nematode  worm,  is  often  found  in  the 
kidney  of  the  horse,  ox  and  dog,  but  is  very  rare  in  man.  Its  site  of 
predilection  in  the  human  kidney  is  the  pelvis.  The  symptoms  which 
it  causes  are  dysuria,  haematuria,  chyluria  and  pyuria.  A  patient 
from  the  tropics  whom  I  had  the  opportunity  of  examining,  arid  in 
whose  urine  ova  were  found,  was  operated  upon  after  I  had  determined 
by  ureteral  catheterization  that  the  milky,  purulent  masses  came 
from  one  kidney.  The  urine  from  the  other  kidney  was  clear.  At 
operation  the  worm  was  not  found  in  the  kidney.  It  must  have  been 
in  the  lymph -vessels  near  the  kidney 

The  distoma  haematobium  (Bilharzii)  is  a  trematode  parasite 
37 


546  DISEASES    OF    THE    KIDNEYS. 

which  is  common  in  Egypt.  It  gets  into  the  intestine  by  means  of 
contaminated  drinking  water  or  food  (dates,  fish  and  other  food) 
and  thence  passes  into  the  kidney,  its  pelvis,  and  the  bladder.  It 
causes  occlusion  of  the  blood-vessels,  inflammation  and  haematuria. 
The  diagnosis  can  be  made  only  by  finding  the  ova  in  the  urine. 
Treatment  must  be  preventive,  the  use  of  contaminated  food  being 
prohibited. 

The  filaria  sanguinis  is  a  nematode  worm  indigenous  in  the  tropics — 
in  Brazil,  the  East  and  West  Indies  and  Egypt.  It  gets  into  the 
intestines  and  occludes  the  lymph-vessels,  as  a  result  of  which  they 
become  dilated  and  the  lymph  from  the  accessory  channels  is  poured 
into  the  bladder  or  kidney.  As  proof  that  this  explanation  of  the 
development  of  chyluria  is  correct,  it  has  been  cited  that  the  thoracic 
duct  is  found  dilated  at  autopsy. 

Incidentally  it  may  be  mentioned  that  Israel  once  diagnosticated  a 
case  of  primary  actinomycosis  of  the  kidney.  The  diagnosis  was 
made  by  finding  actinomyces  in  the  granulations  of  the  scar  of  a 
previous  exploratory  puncture  and  in  the  urine.  With  the  exception 
of  this  case  actinomycosis  has  been  observed  only  as  a  secondary 
process. 

SYPHILIS  OF  THE  KIDNEY. 

Renal  syphilis  is  still  an  obscure  subject.  Until  within  a  short  time 
syphilitic  disease  of  the  kidney  was  considered  exclusively  as  a  mani- 
festation of  general  syphilis,  which  occasionally  affected  both  kidneys 
and  produced  a  diffuse  parenchymatous  and  interstitial  nephritis. 
All  the  cases  which  I  have  seen  were  of  this  form.  Israel  also  describes 
such  a  case  in  which  the  fatty  capsule  was  thickened  and  very  fibrous 
and  the  fibrous  capsule  was  converted  into  a  lardaceous  rind.  Upon 
section  the  kidney  showed  yellow  wedge-shaped  areas  and  marked 
interstitial  and  parenchymatous  changes  (small- celled  infiltration  of  the 
interstitial  tissue,  degeneration  and  complete  destruction  of  the  epithe- 
lium). Thus  far  his  observations  are  fully  in  accord  with  my  opinion, 
that  diffuse  nephritis  may  develop  in  syphilis,  but  Israel  believes  that 
his  case  was  one  of  unilateral  syphilitic  nephritis,  for  the  reason  that 
after  extirpation  of  the  kidney  the  patient  recovered  and  gained  forty 
pounds. 

I  question  the  correctness  of  his  opinion.  According  to  my  experience 
there  is  no  such  a  thing  as  unilateral  nephritis.     I  have  never  seen  a 


SYPHILIS    OF    THE    KIDNEY. 


547 


single  case,  and  this  alleged  one  of  Israel's  only  strengthens  my  belief 
that  it  does  not  exist.  Five  years  after  the  operation  the  patient 
still  had  albumen  in  his  urine,  so  it  is  much  more  probable  that  he  had 
a  bilateral  nephritis,  which  perhaps  was  more  severe  in  the  kidney 
extirpated  and  became  arrested  in  the  other  kidney  after  he  was  oper- 
ated on. 

The  second  case,  one  in  which  a  kidney  which  was  extirpated 
chiefly  on  account  of  a  fistula  was  found  to  have  shiny  yellow  nodules 
on  its  surface  and  to  be  much  contracted,  seems  to  me  to  be  consid- 
erably more  important.  Upon  section  map-like  yellow  areas  were 
found.  The  adjoining  tissue  was  yellow  in  color  and  not  at  all  like 
normal  kidney  substance;  it  proved  to  be  composed  of  connective- 
tissue  cells  having  spindle-shaped  nuclei,  and  was  not  sharply  demar- 
cated from  the  yellow  necrotic  tissue.  This  case  was  one  of  diffuse 
gummata.     The  kidney  was  removed  and  the  patient  recovered. 

The  case  offers  striking  proof  that  gummata  may  affect  one  kidney. 
The  diagnosis  will  always  require  evidence  of  syphilis  or  a  history 
of  this  disease.     It  may  be  confirmed  by  treatment  ex  juvantibus. 

It  has  long  been  known  that  mercury  has  an  unfavorable  influence 
upon  diffuse  nephritis  occurring  in  syphilis  and  that  potassium  iodide 
has  scarcely  any  effect.  Occasionally  the  albumen  is  somewhat 
diminished.  It  may  be  expected,  however,  that  gummata  will  even- 
tually undergo  complete  absorption  under  the  use  of  mercury  and  the 
iodides,  just  as  they  do  in  other  organs.  These  drugs  should  always 
be  tried. 

Extirpation  of  the  kidney  is  permissible  only  when  these  remedies 
have  failed,  and  then  only  after  the  functional  capacity  of  the  other 
kidney  has  been  tested  and  found  to  be  adequate.  In  diffuse  nephritis, 
which  can  be  diagnosticated  by  catheterization  of  the  ureters,  operation 
is  contraindicated. 

[The  existence  of  a  genuine  syphilitic  diffuse  nephritis  was  formerly 
denied,  but  so  many  cases  of  undoubted  authenticity  have  been 
reported  that  its  existence  is  now  generally  recognized.  Cases  occur 
in  which  no  etiological  factors  other  than  syphilitic  infection  can  be 
determined,  the  renal  involvement  manifesting  itself  suddenly  early 
in  the  course  of  the  disease,  even  before  mercurial  treatment  has  lnvn 
instituted.  I  have  observed  two  cases  of  this  kind  in  young  and 
previously  healthy  persons  who  had  neglected  to  take  treatment 
owing  to  the  beni<mitv  of  the  secondarv  manifestations. 


548  DISEASES    OF    THE    KIDNEYS. 

True  syphilitic  nephritis  is  to  be  differentiated  from  the  albumi- 
nuria which  is  so  common  in  beginning  constitutional  syphilis. 
Like  the  latter,  however,  it  usually  occurs  early  in  the  course  of  the 
disease,  according  to  Fournier,  almost  always  within  the  first  year 
after  infection.  Probably  the  majority  of  cases  occur  during  the 
first  four  months  after  infection.  In  one  patient  of  mine  it  came 
on  simultaneously  with  the  early  secondaries,  which  were  unusually 
severe. 

This  affection  is  characterized  by  its  sudden  onset,  by  the  large 
amount  of  albumen  in  the  urine,  and  by  its  rapid  progress.  In 
suddenness  of  onset  it  resembles  the  nephritis  complicating  other 
infectious  diseases.  The  oedema  of  the  eyelids,  ankles,  scrotum 
and  other  parts  is  present,  and  likewise  the  asthenia,  anorexia  and 
oliguria  so  characteristic  of  acute  renal  inflammation. 

As  already  stated,  the  quantity  of  albumen  is  large.  Fifteen  to 
fifty  grammes  per  diem  is  not  an  unusual  amount.  Casts,  at  first 
hyaline  and  light  granular,  and  later  dark  granular  and  epithelial, 
are  also  present  in  the  urine. 

The  tendency  is  for  both  objective  and  subjective  symptoms 
to  progress  rapidly.  The  localized  oedema  may  be  widely  diffused 
within  a  few  days  or  a  fortnight,  and  diarrhoea,  vomiting,  suppression 
of  urine,  uremia  and  pulmonary  oedema  may  lead  to  an  early  fatal 
termination.  Fournier  found  that  ten  out  of  thirty  cases  which  he 
studied  ended  in  death. 

Recovery  may  take  place  or  the  morbid  process  may  become 
chronic. 

In  regard  to  treatment,  it  would  seem  that  in  some  cases  mercurv 
is  entirely  without  effect,  as  stated  above,  whereas  in  others  it  is 
almost  specific.  My  own  experience  is  entirely  in  accord  with  that 
of  Fournier,  Widal,  Mosny,  Le  Gendre,  Siredey  and  others,  who  have 
obtained  excellent  results  in  a  certain  proportion  of  their  cases  by 
the  liberal  administration  of  mercury. 

In  cases  in  which  mercury  is  ineffectual,  Siredey  advises  that  its 
use  be  discontinued  temporarily,  the  patient  confined  to  bed  and 
put  upon  a  milk  diet  for  a  week,  and  that  at  the  expiration  of  this 
time  hypodermatic  injections  of  a  soluble  mercurial  salt  be  tried. 

If  the  patient's  general  condition  improves,  or  if  the  quantity  of 
albumen  excreted  in  the  urine  diminishes,  the  injections  are  con- 
tinued.    If  the  patient  becomes  worse,  or  the  amount  of  albumen 


PERI-,    EPI-,    AND    PARANEPHRITIS.  549 

increases,  they  are  stopped.     I  have  had  the  opportunity  of  trying  this 

plan  in  one  case,  with  the  result  that  the  patient  improved.] 

PERI-,  EPI-,  AND  PARANEPHRITIS. 

Owing  to  the  multiplicity  of  terms  it  is  first  necessary  to  get  a  clear 
conception  of  their  meaning.  Perinephritis  refers  to  inflammation 
of  the  fibrous  capsule,  epinephritis  to  inflammation  of  the  fatty  cap- 
sule, and  paranephritis  to  inflammation  of  the  retroperitoneal  mass  of 
fat  behind  the  kidney.  These  conditions  often  occur  together,  or 
at  least  all  the  structures  are  frequently  affected  when  diagnosis  is 
first  made,  although  in  the  beginning  of  the  disease  one  or  another 
was  primarily  affected. 

As  an  independent  and  isolated  affection  perinephritis  is  the  most 
common.  It  produces  thickening  of  the  capsule  and  causes  it  to 
become  adherent  to  the  parenchyma  of  the  kidney,  with  the  result 
that  small  subcapsular  areas  of  suppuration  develop.  The  fibrous 
capsule  can  then  be  stripped  off  from  the  kidney  only  with  difficulty, 
or  perhaps  not  at  all.  If  it  be  torn  off  with  force  small  pieces  of  the 
kidney  are  brought  away  with  it. 

This  perinephritis,  which  is  frequently  though  not  always  associated 
with  other  renal  affections,  gives  rise  to  pain  which  may  sometimes 
be  so  severe  as  to  resemble  typical  renal  colic.  It  is  due  to  traction 
exerted  upon  the  kidney  and  its  nerves  by  the  adhesions.  The  con- 
dition is  important  because  it  offers  an  explanation  of  many  obscure 
cases  of  renal  colic  in  which  no  abnormalities  are  found  at  operation. 

Epinephritis  and  paranephritis  develop  primarily  from  wounds 
and  contusions  in  the  region  of  the  kidney  and  secondarily  from  metas- 
tases or  extension  of  inflammation  from  neighboring  parts.  In 
the  latter  respect  it  is  not  merely  inflammation  of  the  kidney  which 
invades  the  epinephric  and  paranephric  tissue;  suppuration  in  the 
pelvic  cavity,  parametric  and  paratyphlitic  suppuration,  ileopsoas 
abscess,  and  burrowing  abscesses  in  organs  higher  up,  such  as  the  liver, 
spleen  and  lungs,  as  well  as  subphrenic  abscess  and  empyema,  may 
lead  to  suppuration  in  the  fatty  and  fibrous  tissue  around  the  kidney. 

The  entire  part  is  then  the  seat  of  a  more  or  less  extensive  circum- 
scribed or  diffuse  suppuration.  A  typical  phlegmon  is  formed  which 
may  rupture  into  neighboring  organs.  Rupture  has  taken  place  into 
the  kidney,  ureter,  peritoneal  cavity,  intestine,  bladder,  diaphragm, 
and  also  through  the  ileopsoas  muscle  onto  the  hip. 


550  DISEASES    OF    THE    KIDNEYS. 

Recognition  of  the  disease  in  its  beginning  is  very  difficult  or  even 
impossible,  owing  to  the  concealed  situation  of  the  lesion  and  to  predom- 
ination of  symptoms  referable  to  other  affections,  such  as  suppuration 
in  the  kidney  and  liver,  for  instance.  It  is  only  as  the  disease 
progresses  that  its  nature  becomes  clear.  Pain,  fever  and  tumefaction 
are  the  cardinal  symptoms.  The  pain  is  located  in  the  affected  part, 
becomes  more  severe  upon  motion  and  when  the  body  is  shaken  or 
jolted,  and  particularly  when  pressure  is  made  over  the  kidney. 
It  may  be  so  severe  as  to  prevent  all  motion  and  even  force  the  patient 
to  refrain  from  coughing. 

Fever  may  be  high  or  low,  or  may  be  altogether  absent.  It  is 
generally  intermittent  or  remittent.  Tumefaction  becomes  more 
perceptible  as  the  morbid  process  advances  toward  the  surface.  It 
differs  from  renal  tumors  in  that  it  is  more  diffuse.  While  the  former 
can  usually  be  well-defined  and  their  limits  determined,  the  latter 
gradually  becomes  continuous  with  the  normal  tissue,  no  distinct  line 
of  demarcation  existing.  In  consequence  of  this  intimate  connection 
with  the  surrounding  tissues,  the  mass  does  not  move  so  freely  with 
respiration  as  do  renal  tumors.  If  the  inflammation  reaches  the  skin 
the  phlegmon  becomes  apparent.  The  skin  is  reddened,  tense  and 
swollen.  Pressure  is  painful.  The  symptoms  of  rupture  depend  upon 
what  organ  is  perforated. 

The  urine  usually  shows  no  change  unless  the  kidney  is  involved. 

The  course  of  this  disease  is  most  favorable  when  early  external 
rupture  takes  place.  Otherwise  it  depends  upon  the  organ  into  which 
rupture  occurs. 

Treatment  consists  in  making  free  incisions  into  the  phlegmonous 
area  and  evacuating  the  pus.  Internal  and  local  antiphlogistic  meas- 
ures are  not  to  be  relied  upon,  as  the  infected  areas  will  not  be  influenced 
by  them.  If  the  kidney  is  also  diseased,  as  is  often  the  case,  it  should 
be  incised,  and  if  it  is  found  to  be  mostly  destroyed  it  should  be  removed. 

INJURIES  OF  THE  KIDNEY. 

Injuries  of  the  kidney  are  not  very  common.  They  are  divided 
into  wounds  and  contusions.  Wounds  are  caused  by  gunshot  injuries, 
stabs  and  blows.  A  renal  wound  may  be  simple  or  may  be  complicated 
with  wounds  of  other  organs,  such  as  the  intestine  or  peritoneum. 
It  is  plain  that  the  latter  are  the  more  serious. 

The  chief  danger  of  a  kidney  wound  is  hasmorrhage.     The  blood 


CONTUSIONS    OF    THE    KIDNEY. 


551 


may  escape  from  the  wound  or  flow  into  the  renal  pelvis  and  thence 
through  the  ureter  to  the  bladder,  or  it  may  be  poured  out  into  the 
perinephric  tissue. 

Infection  is  also  to  be  feared.  It  may  be  caused  by  germs  introduced 
from  without,  or  take  place  within  the  kidney.  If  the  haemorrhage 
is  profuse  clots  may  occlude  the  ureter  and  cause  typical  renal  colic. 
Haematuria  then  suddenly  ceases.  Clots  too  large  to  pass  through  the 
urethra  or  a  catheter  may  cause  retention  of  urine  and  great  distention 
of  the  bladder,  and  thus  give  rise  to  vesical  spasm. 

The  prognosis  of  wounds  of  the  kidney  depends  upon  their  severity. 
Many  heal  kindly  and  many  become  infected  and  suppurate.  A  part 
or  the  whole  of  the  kidney,  together  with  the  perinephric  tissue,  may 
suppurate  and  cause  pyaemia. 

Treatment.  In  small  wounds  treatment  should  be  confined  to 
washing  out  the  wound  and  applying  an  antiseptic  dressing.  In 
severe  wounds  in  which  there  is  danger  of  haemorrhage  the  injured 
kidney  must  be  freely  exposed.  If  bleeding  cannot  be  arrested  by 
packing  extirpation  of  the  kidney  is  indicated.  If  suppuration  occurs 
before  the  surgeon  sees  the  case,  incision  and  drainage  must  always 
be  practised.  Vesical  tenesmus  is  treated  according  to  established 
rules.  If  the  clots  cannot  be  removed  through  the  catheter,  and  if 
vesical  tenesmus  persists,  suprapubic  cystotomy  must  be  performed. 

CONTUSIONS  OF  THE  KIDNEY. 

A  contusion  of  the  kidney  is  an  injury  of  the  organ  in  which  the 
superjacent  soft  parts  are  not  divided.  They  are  usually  caused 
by  direct  force,  such  as  blows,  kicks  or  crushes.  The  extent  of 
the  contusion  is  variable.  It  may  be  confined  to  the  capsule,  involve 
a  portion  of  the  kidney,  or  extend  into  the  pelvis  and  ureter. 

The  unmistakable  symptoms  of  contusion  of  the  kidney  are  urinary 
haemorrhage  and  the  formation  of  a  tumor  in  the  region  of  the  kidney. 
If  the  peritoneum  is  torn  blood  may  be  effused  into  the  peritoneal 
cavity  and  produce  peritonitis-.  Sometimes,  particularly  when  the 
injury  is  slight,  the  bleeding  ceases  of  its  own  accord.  If  it  has  been 
slight  from  the  beginning  one  may  wait  a  little  while,  but  unless  it 
ceases,  or  if  signs  of  anaemia  appear,  delay  is  not  permissible.  The 
injured  organ  must  then  be  exposed.  If  possible,  the  wound  should 
be  closed  with  sutures,  otherwise  it  should  be  packed  with  gauze; 
if  packing  fails  to  arrest  the  bleeding  nephrectomy  must  be  performed. 


552  DISEASES    OF    THE    KIDNEYS. 

The  prognosis  of  contusions  of  the  kidney  depends  entirely  upon 
their  severity  and  the  quickness  with  which  help  is  secured.  In  severe 
cases  death  may  result  from  haemorrhage. 

ANEURYSM  OF  THE  RENAL  ARTERY. 

This  very  rare  affection  depends,  the  same  as  aneurysm  of  other 
vessels,  upon  arteriosclerosis,  and  accordingly  is  observed  only  in 
elderly  persons,  often  being  associated  with  similar  disease  in  other 
vessels.  Diagnosis  during  life  is  very  difficult  and  has  been  made  in 
only  a  few  cases. 

A  tumor,  hematuria  and  pain  are  the  principal  symptoms.  They 
may  be  absent,  and  as  they  also  occur  in  other  renal  diseases  they 
afford  no  positive  information. 

Haematuria  is  a  symptom  of  multifarious  significance,  and,  moreover, 
in  aneurysm  it  generally  occurs  late  in  the  course  of  the  disease.  Finally, 
the  tumor  is  of  diagnostic  import  only  when  it  pulsates.  This  it  does 
not  always  do,  as  for  example,  when  it  is  filled  with  clots.  A  pulsating 
tumor  might  also  be  a  mass  lying  upon  the  aorta,  or  an  aneurysm  of 
some  other  branch  of  the  abdominal  aorta.  In  addition  to  all  this 
a  palpable  tumor  is  not  always  present.  Thus  it  is  seen  that  diagnosis 
is  most  difficult,  and,  indeed,  usually  impossible.  It  is  only  when  a 
pulsating  tumor  is  associated  with  haematuria  that  we  have  a  right  to 
assume  the  existence  of  aneurysm. 

As  concerns  treatment  Hahn's  case  is  of  interest.  His  patient 
recovered  after  ablation  of  the  aneurysmal  sac  together  with  the 
corresponding  kidney.  [Albert  and  Keen  have  also  operated  success- 
fully for  this  condition.  In  1900  Dr.  Keen  was  able  to  collect  only 
thirteen  cases  including  his  own;  later  in  the  same  year  Henry  Morris 
reviewed  the  literature  of  the  subject  and  brought  the  number  up 
to  nineteen.  In  1903  Paul  Zeigler,  of  Munich,  in  a  still  more  exhaus- 
tive review  of  the  literature,  found  three  other  cases,  thus  making 
the  total  number  twenty-two.  Since  the  publication  of  Zeigler's 
paper,  so  far  as  I  have  been  able  to  determine,  only  one  case  has 
been  reported,  namely,  one  by  Dr.  C.  W.  Higgins,  of  Providence", 
R.  I.  Thus  it  is  seen  that  the  condition  is  rare,  although  many 
cases  may  have  occurred  in  which  a  correct  diagnosis  was  not  made 
either  before  or  after  death. 

In  thirteen  of  the  twenty-three  recorded  cases  there  was  a  history 


> 

X 
X 

LU 

< 
cu 


NEURALGIA    OF    THE    KIDNEY.  553 

of  injury,  in  seven  no  injury  had  been  sustained,  and  in  three  no  history 
was  obtainable. 

It  is  interesting  to  note  that  recovery  took  place  in  the  three  cases 
in  which  operation  was  performed.  Those  due  to  injury  naturally 
offer   the   most   favorable   prognosis.] 

NEURALGIA  OF  THE  KIDNEY  (NEPHRALGIA,  NEPHRALGIE 
HjEMATURIQUE,  ANGIONEUROSIS  RENIS,  ESSEN- 
TIAL HEMATURIA,  HAEMORRHAGE 
FROM  HEALTHY  KIDNEYS). 

In  preceding  sections  mention  has  been  made  of  a  series  of  affections 
which  are  associated  with  pain,  especially  with  proxysmal  attacks  of 
colic.  It  is  known  that  any  obstruction  in  the  ureter  may  cause 
renal  colic.  Thus  it  may  be  due  to  renal  and  ureteral  calculi,  kinking 
of  the  ureter  owing  to  low  position  of  the  kidney,  movable  kidney, 
hydronephrosis,  occlusion  due  to  blood-clots  or  pus  resulting  from  new 
growth,  parasites,  tuberculosis  and  pyonephrosis. 

For  many  years,  however,  cases  of  typical  renal  colic  have  been 
recognized  in  which  none  of  these  affections  were  demonstrable  nor 
could  be  found  upon  operation  or  at  autopsy. 

The  complaint  under  discussion  is  characterized  either  by  violent 
pain  in  the  region  of  the  kidney,  resembling  true  renal  colic  and  recur- 
ring at  variable  intervals,  or  by  colic  associated  with  more  or 
less  severe  haemorrhage,  which  is  also  of  variable  duration.  In  a 
third  class  of  cases  the  only  symptom  observed  is  renal  haemorrhage, 
which  at  times  is  of  long  duration.  It  is  self-evident  that  affections 
in  which  other  symptoms  are  present,  for  example,  pus  and  blood  in 
the  urine,  cannot  be  placed  in  this  category. 

How  are  these  cases  to  be  explained  ?  In  view  of  the  fact  that  haem- 
orrhage of  great  severity  and  long  duration  has  been  observed  inde- 
pendently of  any  of  the  recognized  causes  of  renal  bleeding,  and  par- 
ticularly for  the  reason  that  persons  thus  affected  have  enjoyed  good 
health  for  years  afterwards  without  the  supervention  of  other  haem- 
orrhages, it  has  been  assumed  that  the  trouble  is  due  to  disturbances 
of  the  vasomotor  and  sensory  nerves,  or  in  other  words  that  the  haem- 
orrhages are  angioneurotic  (Klemperer). 

Senator  explained  one  case  by  the  hypothesis  of  renal  haemophilia. 
Israel  is  of  the  opinion  that  this  case  depended  upon  the  structural 
changes  in  the  kidney.     He  believes  that  in  such  cases  there  is  a  pre- 


554  DISEASES    OF    THE    KIDNEYS. 

existent  circumscribed  or  diffuse  inflammation,  which  produces  no 
changes  in  the  urine,  but  gives  rise  to  paroxysmal  attacks  of  conges- 
tion. Naunyn  has  also  reported  violent  haemorrhages  in  contract- 
ing kidney. 

Harrison,  Guyon,  Albarran  and  Legueu  are  likewise  of  the  opinion 
that  the  condition  is  due  to  congestive  swelling  of  the  kidney  resulting 
from  old  inflammatory  foci  and  leading  to  tension  of  the  capsule. 
They  also  believe  that  the  condition  can  be  cured  by  splitting  the 
capsule  of  the  kidney. 

Senator  and  Rovsing  think  that  there  are  always  adhesions  between 
the  kidney  and  fibrous  capsule  and  the  fibrous  and  fatty  capsule,  and 
that  the  pain  is  caused  by  traction.  They  believe  the  curative  effect 
produced  by  splitting  the  kidney  to  be  due  to  the  fact  that  the 
adhesions  are  broken  up  when  the  organ  is  freed  from  its  investing 
layers.  Therefore,  Rovsing  advises  against  incising  the  kidney  and 
recommends  that  it  be  merely  freed  from  its  surrounding  membranes, 
to  which  operation  he  applies  the  term  nephrolysis. 

As  concerns  my  own  experience,  I  have  seen  cases  of  typical  renal 
colic  which  differed  in  no  wise  from  those  due  to  calculi  except  that 
no  red  blood-cells  were  present  in  the  urine,  cases  in  which  no  discernible 
lesions  were  found  upon  operation  and  in  which  microscopic  exam- 
ination of  sections  of  renal  tissue  removed  at  the  time  of  operation 
showed  no  abnormalities.  In  these  cases,  moreover,  the  patients 
recovered  and  experienced  no  return  of  their  disease. 

In  one  of  these  cases  just  before  each  attack  the  kidney  became 
so  swollen  that  it  could  be  easily  palpated  under  the  costal  arch;  after 
the  attack  the  swelling  disappeared.  At  operation  (nephrotomy) 
neither  hydronephrosis  nor  dilatation  of  the  pelvis  was  found.  In 
this  case  there  could  have  been  nothing  but  congestion  and  increase 
in  the  volume  of  the  kidney.  No  cause  for  this  condition  was 
ascertainable;  one  is  forced  to  accept  the  hypothesis  of  spasm  of  the 
ureter.  This  theory  is  corroborated  by  another  observation.  In  two 
other  cases  I  merely  decapsulated  the  kidney  and  in  both  perfect  and 
permanent  cure  was  obtained.  I  have  never  seen  a  nephritis  cause 
typical  renal  colic  unless  some  other  condition  was  also  present.  I 
have  often  seen  cases  in  which  there  was  severe  pain  in  the  back,  but 
it  was  not  sufficiently  violent  to  constitute  renal  colic.  I  have  yet 
to  see  a  case  of  unilateral  nephritis. 

It  is  true  that  profuse  haemorrhages  may  occur  in  nephritis  and  that 


NEURALGIA    OF    THE    KIDNEY. 


555 


the  resulting  blood-clots  may  occlude  the  ureter  and  thus  give  rise  to 
colic,  but  this  is  quite  another  thing  than  the  one  now  under  consider- 
ation. Stenosing  ureteritis,  which  also  occasionally  gives  rise  to  colic, 
must   likewise   be   excluded. 

I  have  seen  three  cases  of  severe  haemorrhage  from  both  kidneys  in 
apparently  healthy  persons.  In  the  beginning  these  cases  were 
puzzling,  as  the  patients  presented  no  symptoms  after  the  bleeding 
subsided.  Upon  continued  careful  examination,  however,  I  found 
intermittent  albuminuria  and  casts  in  all  three.  These,  then,  were 
cases  of  chronic  nephritis  with  paroxysmal  attacks  of  profuse 
haemorrhage. 

The  following  case  is  also  important.  I  once  relieved  a  patient 
suffering  from  complete  anuria  and  violent  renal  colic  by  passing  a 
catheter  into  the  ureter  on  the  affected  side.  The  anuria  was  imme- 
diately overcome  and  the  colic  disappeared.  No  stone  was  passed 
nor  was  any  seen  upon  subsequent  cystoscopic  examination. 

Having  thus  reviewed  this  somewhat  obscure  subject  I  will  now 
express  my  own  views  in  regard  to  it. 

There  are  cases  of  renal  colic  without  any  obstruction  in  the  ureter 
which  are  caused  by  firm  adhesions  between  the  true  capsule  of  the 
kidney  and  the  surrounding  fatty  capsule.  For  these  decapsulation 
is  the  proper  treatment.     Splitting  the  kidney  should  be  abandoned. 

It  has  not  yet  been  determined  whether  there  is  a  local  renal  haem- 
ophilia or  bleeding  from  healthy  kidneys,  nor  whether  circumscribed 
nephritic  areas  may  produce  renal  colic.  It  is  well-known,  though, 
that  severe  haemorrhage  may  occur  in  chronic  nephritis. 

There  are  spasms  of  the  ureter  for  which  no  cause  can  be  found. 
They  are  comparable  to  the  cramps  occurring  in  hysteria  and  to  the 
gastric  crises  of  tabes,  for  which  reason  they  have  been  called  crises 
nephretiques.  They  may  lead  to  typical  renal  colic.  As  a  rule,  they 
are  cured  by  simple  catheterization  of  the  ureter. 

If  the  attacks  of  colic  are  associated  with  severe  haemorrhage,  there 
is  in  the  majority  of  cases  an  underlying  structural  change  acting  as 
the  cause.  The  circumstance  that  no  bleeding  occurs  for  years  after 
does  not  prove  the  contrary,  for  we  know  that  haemorrhage  from 
malignant  tumors  may  cease  for  years  at  a  time. 

Whether  there  is  an  underlying  structural  cause  or  whether  the 
bleeding  is  angioneurotic  (the  existence  of  which  form  I  do  not  consider 
proved)  would  be  determined  by  catheterization  of  the  ureters,  together 


556  DISEASES    OF    THE    KIDNEYS. 

with  functional  examination  of  the  kidney.  It  is  natural  to  suppose 
that  a  kidney  with  structural  lesions  will  not  work  as  well  as  its  fellow. 
Unfortunately  I  have  had  the  opportunity  of  examining  only  one 
such  case.  Experience  must  teach  whether  the  differences  in  the 
functional  values  of  both  kidneys  are  so  great  that  positive  conclusions 
can  be  drawn  from  them. 

[THE   OPERATIONS  OF  NEPHROTOMY  AND  NEPH- 
RECTOMY.] 

To  expose  the  kidney  through  the  lumbar  route,  the  patient  is  placed 
on  the  sound  side  with  a  sand-pillow  or  an  inflated  cylindrical  rubber 
pad  beneath  the  loin,  and  an  incision  commencing  half  an  inch  below 
the  twelfth  rib,  close  to  the  outer  border  of  the  erector  spinas  muscle, 
is  carried  obliquely  downwards  and  outwards  towards  the  crest  of  the 
ilium  for  a  distance  of  three  inches  or  more,  perhaps  being  made  to 
curve  slightly  forward  at  its  lower  extremity  toward  the  abdomen, 
parallel  with  and  about  a  half  inch  above  the  crest  of  the  ilium.  The 
latter  modification  will  be  found  serviceable  in  the  case  of  obese 
persons.  The  first  cut  divides  skin,  superficial  fascia  and  fat,  thus 
exposing  the  muscular  layer  formed  by  the  latissimus  dorsi  behind 
and  the  external  oblique  in  front.  This  layer  is  then  cut  through  and 
the  internal  oblique,  the  lumbar  fascia,  and  perhaps  also  some  muscular 
fibers  of  the  serratus  posticus  inferior,  are  brought  into  view.  The 
divided  tissues  are  now  drawn  back  with  retractors  so  as  to  give  a  good 
exposure  of  the  field  of  operation. 

The  twelfth  dorsal  nerve,  which  emerges  from  beneath  the  quad- 
ratus  lumborum  muscle,  pierces  the  aponeurosis  of  origin  of  the 
transversalis  abdominis,  and  then  passes  onwards  between  this  latter 
muscle  and  the  internal  oblique,  should  now  be  sought  for  and 
drawn  away  from  the  line  of  incision  through  the  lumbar  fascia. 

The  ilio-hypogastric,  which  lies  below  the  twelfth  dorsal,  must  be 
avoided.  Occasionally  a  portion  of  the  ilio-inguinal  may  be  ex- 
posed. 

It  will  usually  be  necessary  to  prolong  this  incision  into  the  substance 
of  the  internal  oblique.  The  incision  should  be  begun  a  little  anterior  to 
the  erector  spinae  mass  so  as  to  avoid  opening  the  sheath  of  this  muscle. 
Care  must  be  taken,  however,  not  to  begin  it  too  far  anteriorly  lest  the 
peritoneum   be    divided.     Haemorrhage    from   the   branches   of   the 


THE    OPERATIONS    OF    NEPHROTOMY    AND    NEPHRECTOMY.         557 

subcostal  and  lumbar  arteries,  if  of  any  moment,  should  be  arrested 
by  tying  the  vessels. 

The  perirenal  fat  bulges  through  the  incision  in  the  lumbar  fascia, 
and  is  to  be  divided  with  the  knife  or  separated  by  blunt  dissection, 
whereupon  the  kidney  can  be  forced  out  of  its  position  into  the  wound 
by  making  pressure  upon  the  abdominal  wall. 

There  are  two  points  concerning  the  fatty  capsule  of  the  kidney 
which  it  is  well  not  to  forget ;  one  is  anatomical,  the  other  pathological. 

As  regards  the  first,  bear  in  mind  that  there  is  a  distinct  layer  of 
fascia  embedded  in  the  substance  of  the  fatty  capsule  which  may  be 
mistaken  for  peritoneum  unless  its  existence  be  thought  of  when  it 
is  exposed.     (See  also  under  anatomy  of  the  kidney.) 

The  second  has  reference  to  the  changes  produced  in  the  capsule 
by  inflammation,  as  the  result  of  which  it  becomes  converted  into  a 
dense,  firm  mass  difficult  to  break  through  and  adherent  to  the  true 
fibrous  capsule.  The  separation  or  removal  of  such  a  mass  is  tedious, 
and  considerably  prolongs  the  time  required  for  operation. 

If  sufficient  room  is  not  secured  by  this  method  to  bring  the  kidney 
into  full  view,  various  modifications  may  be  employed  according  to 
the  exigencies  of  the  individual  case.  Thus,  the  quadratus  lumborum 
muscle  may  be  divided  at  right  angles  to  its  fibers,  the  original  incision 
prolonged  further  downwards,  or  the  twelfth  rib  may  be  divided  or 
resected. 

Instead  of  the  oblique  incision  a  longitudinal  one  may  be  made  along 
the  border  of  the  erector  spinas  mass  from  the  twelfth  rib  down  to  the 
crest  of  the  ilium.  Edebohls,  who  employs  this  incision,  places  the 
patient  in  the  prone  position  with  an  inflated  cylindrical  rubber  bag 
beneath  his  abdomen.  When  the  cutaneous  and  muscular  layers 
have  been  divided,  the  patient  is  pulled  by  the  legs  toward  the  foot 
of  the  table,  the  pad  thus  being  brought  under  the  thorax.  The 
abdominal  breathing  which  results  from  this  manipulation  serves  to 
force  the  kidney  out  of  the  wound. 

After  the  kidney  has  been  exposed  the  method  of  treating  it  will 
depend  entirely  upon  the  morbid  condition  present. 

When  operating  for  the  removal  of  calculi  (nephrolithotomy)  an 
effort  may  be  made  to  detect  the  stone  by  palpating  the  kidney  with 
the  finger  or  exploring  it  with  a  needle.  If  calculi  are  detected  they 
are  to  be  cut  down  upon  and  removed  with  the  fingers,  forceps  or 
scoop.     There  is  always  a  possibility,  however,  of  leaving  small  calculi 


558  DISEASES    OF    THE    KIDNEYS. 

behind  unless  the  interior  of  the  kidney — the  calices,  pelvis  and  origin 
of  the  ureter — be  thoroughly  explored.  Therefore  it  is  better  to  lay 
the  kidney  freely  open  and  explore  the  depths  with  a  probe.  In  doing 
this  the  manner  of  making  the  incision  is  of  some  moment. 

Brodel's  study  of  the  blood-supply  of  the  kidney  has  taught  us  that 
the  anterior  half  is  much  more  vascular  than  the  posterior.  Hence 
the  first-named  portion  is  to  be  avoided  when  the  organ  is  incised. 

An  incision  made  six  millimeters  behind  the  convex  border  of  the 
kidney  will  pass  between  the  anterior,  highly  developed  plexus  and  the 
posterior  plexus,  thus  considerably  lessening  division  of  blood-vessels 
(Kelly).     (See  also  under  anatomy  of  the  kidney. ) 

The  renal  artery  must  be  compressed  before  the  kidney  is  cut  into, 
and  the  compression  must  be  maintained  until  the  renal  wound  is 
closed.  For  suturing  this  wound  two  or  three  rows  of  catgut  are  to  be 
used,  so  that  both  its  deep  and  superficial  portions  may  be  brought 
into  good  apposition. 

If  suppuration  exists  to  any  degree,  the  wound  should  be  drained, 
and  not  closed. 

Under  such  circumstances  the  respective  indications  for  nephrotomy 
and  nephrectomy  have  already  been  stated  {see  Nephrolithiasis, 
Pyonephrosis,  etc.). 

In  operating  for  pyonephrosis  the  surrounding  tissues  must  be  pro- 
tected from  contamination.  It  often  happens  that  adhesions  have 
firmly  fixed  the  kidney  to  the  superficial  structures,  thus  obviating  the 
necessity  of  packing  off  with  gauze  or  suturing  the  fatty  capsule  to 
the  external  wound  before  evacuating  the  pus. 

After  the  abscess  cavity  is  opened  and  the  contents  evacuated,  the 
finger  should  be  passed  into  it  and  any  bands  or  partitions  of  tissue 
which  divide  it  into  separate  compartments,  or  project  from  its  walls, 
broken  down  so  as  to  make  a  single  large  cavity. 

When  this  has  been  done  the  cavity  is  irrigated  with  hot  normal 
salt-solution,  a  large  drain  properly  surrounded  by  gauze  introduced, 
and  a  few  sutures  put  in  at  either  end  of  the  external  incision. 

It  is  often  advisable  to  suture  the  walls  of  the  renal  wound  to  the 
opening  in  the  muscular  layer.     This  effectually  fixes  the  kidney. 

Irrigation  of  the  abscess  cavity  should  be  frequently  employed. 
The  tube  is  gradually  withdrawn  as  healing  takes  place. 

Nephrectomy,  or  the  removal  of  a  kidney,  may  be  performed 
either  through  a  lumbar  or  an  abdominal  incision. 


THE    OPERATIONS    OF    NEPHROTOMY    AND    NEPHRECTOMY.         559 

For  lumbar  nephrectomy  either  of  the  incisions  already  described 
will  usually  suffice,  although  various  others  have  been  devised.  For 
the  removal  of  very  large  growths  that  of  Konig  may  be  employed. 
This  incision  is  carried  along  the  border  of  the  erector  spinas  mass 
nearly  down  to  the  crest  of  the  ilium  and  then  curved  forwards  and 
upwards  towards  the  umbilicus,  stopping  at  the  border  of  the 
rectus. 

After  the  kidney  has  been  exposed  and  separated  from  the  perito- 
neum, it  is  lifted  out  of  the  wound,  the  structures  forming  the  pedicle 
are  isolated  and  ligated  separately  with  strong  silk,  and  the  pedicle 
then  divided  close  to  the  hilum  of  the  kidney.  If  it  is  difficult  or 
impossible  to  isolate  the  constituent  structures  of  the  pedicle,  a  clamp 
is  placed  upon  it  close  to  the  kidney  and  it  is  then  cut  through,  after 
which  the  divided  vessels  and  ureter  are  ligatured  in  the  stump. 

Care  must  be  taken  to  arrest  all  haemorrhage.  If  the  bleeding 
vessels  cannot  be  caught  with  haemostatic  forceps  and  tied,  the  wound 
must  be  firmly  packed  with  gauze.  More  than  one  patient  has  died 
of  haemorrhage  from  an  anomalous  artery  which  was  not  included  in 
the  primary  ligatures. 

When  the  ureter  is  much  diseased,  as  for  instance  when  a  suppurative 
process  has  extended  to  it  from  the  kidney,  it  should  be  fastened  into 
the  edges  of  the  wound  instead  of  being  ligated.  In  some  cases  it 
will  be  possible  to  remove  a  portion  of  the  ureter  and  draw  the  end 
into  the  wound.  This  procedure  permits  the  ablation  of  an  additional 
amount  of  diseased  tissue. 

In  operating  for  malignant  growths  any  remnants  of  the  fatty 
capsule  must  be  scrupulously  removed,  as  it  has  been  shown  that  this 
tissue  often  contains  neoplastic  cells  (Israel,  Lecene). 

The  wound  is  closed  in  the  usual  manner,  space  being  left,  however, 
for  a  drainage  tube. 

Abdominal  nephrectomy  is  suitable  for  the  removal  of  very  large 
growths. 

The  incision  is  made  through  the  linea  semilunaris,  being  four 
inches  long,  with  its  center  corresponding  to  the  umbilicus.  The 
opening  thus  made  may  be  enlarged  above  or  below  if  necessary. 

After  the  abdominal  cavity  has  been  opened  the  hand  is  introduced 
and  the  opposite  kidney  felt  for;  if  it  be  present  and  not  grossly  diseased 
the  operation  is  continued. 

The  intestines  are  pushed  toward  the  median  line  and  the  field  of 


560  DISEASES    OF    THE    KIDNEYS. 

operation  surrounded  with  gauze.  The  peritoneum  covering  the 
kidney  is  then  incised,  dissected  up,  and  drawn  away  from  the  kidney 
on  either  side  by  means  of  haemostatic  forceps  applied  to  either 
edge. 

It  is  important  that  the  peritoneum  be  incised  external  to  the  colon, 
so  that  the  blood-supply  of  the  latter  may  not  be  interfered  with. 

After  the  kidney  is  exposed  it  is  freed  mostly  by  blunt  dissection 
with  the  fingers,  scissors  being  used  only  to  liberate  confining  bands 
of  fibrous  tissue;  the  structures  forming  the  pedicle  are  then  isolated 
and  tied  separately,  the  pedicle  divided  and  the  kidney  removed.  All 
bleeding  is  arrested,  the  wound  in  the  peritoneum  closed  with  catgut, 
all  gauze  removed  from  the  abdominal  cavity,  and  the  opening  in  the 
parietes  closed  in  the  usual  manner. 

In  partial  nephrectomy,  which  is  permissible  only  for  the  removal 
of  benign  growths,  cysts,  strictly  circumscribed  areas  of  suppuration, 
fistulas,  and  portions  of  tissue  destroyed  by  injury  (Hartman),  ablation 
of  the  diseased  tissue  is  practised  and  the  margins  of  the  resulting 
wound  approximated  with  catgut. 

EXAMINATION  AND  DISEASES  OF  THE  URETERS. 

The  ureters  connect  the  kidneys  with  the  bladder.  It  is  very  seldom 
that  we  have  to  do  with  isolated  diseases  of  these  organs,  there  gen- 
erally being  an  associated  lesion  of  the  kidney  or  bladder  and  perhaps 
of  both.  The  ureters  he  concealed  in  the  true  pelvis  and  abdomen 
and  under  normal  conditions  cannot  be  felt  through  the  abdominal 
walls.  When  diseased  they  can  sometimes  be  palpated  through  the 
abdomen  and  rectum,  and  in  the  female  through  the  vagina. 

Palpation  of  the  upper  portion  of  the  ureter  through  the  abdom- 
inal wall,  however,  is  most  uncertain.  It  is  only  in  thin  persons, 
and  when  the  rectum  is  empty  and  the  ureter  much  thickened,  that 
they  can  be  accurately  palpated. 

Favorable  conditions  are  also  necessary  for  palpation  of  the  lower 
segment  through  the  rectum.  The  patient  must  not  be  fat,  the 
examiner's  fingers  must  be  of  good  length  and  the  ureter  somewhat 
thickened.  It  can  then  be  felt  internal  to  and  above  the  seminal 
vesicle  as  a  cord  which  rolls  under  the  finger.  In  the  female  this 
examination  is  comparatively  easy  through  the  vagina.  All  in  all, 
however,  these  methods  of  examination  remain  difficult,  untrustworthy, 


EXAMINATION    AND    DISEASES    OF    THE    URETERS.  56 1 

and  mostly  without  result,  as  one  can  seldom  reach  a  definite  conclusion 
which  will  permit  operation. 

For  this  reason  other  methods  of  examination  have  long  been  sought 
for.  Their  object  is  to  secure  the  urine  from  each  kidney  separately 
and  thus  determine  which  side  is  diseased.  It  is  unnecessary  to 
describe  all  of  these  methods,  for  although  some  of  them  are  very 
ingenious  none  are  of  practical  value.  This  problem  remained 
unsolved  until  I  succeeded  in  placing  catheterization  of  the  ureters 
upon  a  practical  basis. 

It  has  already  been  stated  that  there  are  few  isolated  diseases  of  the 
ureters.  Catheterization  of  the  ureters,  therefore,  affords  an  adequate 
means  of  diagnosticating  diseases  of  the  kidney  as  well  as  offering 
material  assistance  in  the  recognition  of  affections  of  the  ureter.  It  is 
indicated,  however,  only  when  the  simpler  methods  fail. 

The  principal  affections  of  the  ureters  are  injuries,  fistulae,  inflam- 
mation, stricture,  calculi  and  tuberculosis. 

Injuries  may  be  simple  contusions,  ruptures  or  wounds.  The 
first  two  are  very  rare.  The  most  common  are  wounds  inflicted  during 
an  operation,  for  example,  during  vaginal  and  also  abdominal  hys- 
terectomy. The  diagnosis  is  generally  easy,  but  occasionally  there 
is  some  doubt  as  to  which  ureter  is  injured  or  in  what  portion  the 
injury  is  located.  The  passage  of  a  catheter  will  at  once  clear  up  the 
difficulty. 

[If  the  ureter  is  divided  close  to  the  bladder  the  proximal  end  may 
be  implanted  into  the  bladder. 

If  the  division  has  occurred  higher  up,  the  distal  end  may  be  ligated 
and  an  anastomosis  made  between  the  proximal  end  and  a  longitudinal 
slit  in  the  distal  end  below  the  point  of  ligation  (Van  Hook).] 

It  is  the  same  with  ureteral  fistulae,  nearly  all  of  which  are  of 
traumatic  origin.  An  ulcerating  tumor  or  tubercle  in  the  ureter  may 
rarely  lead  to  the  spontaneous  formation  of  a  fistula. 

Inflammation  of  the  ureters,  ureteritis  and  periureteritis,  occur 
only  in  association  with  an  ascending  process  from  the  bladder  or  a 
descending  one  from  the  kidney.  The  symptoms,  therefore,  are 
identical  with  those  of  the  respective  renal  and  vesical  affections. 

A   distinction   of   more   practical    importance    exists   between   the 

isolated  forms,  as  some  are  associated  with  dilatation  of  the  ureter 

and  others  with  narrowing  and  kinking.     The  last  two  conditions 

can  be  positively  diagnosticated  by  catheterizing  the  ureters.     If  the 

38 


562  DISEASES    OF    THE    KIDNEYS. 

catheter  repeatedly  becomes  arrested  at  the  same  place,  the  existence 
of  one  or  the  other  of  these  conditions  may  be  assumed  unless  symp- 
toms of  obstruction  due  to  some  other  cause,  such  as  tumor  or  stone, 
are  present. 

[The  late  Christian  Fenger,  of  Chicago,  applied  the  principle  of 
the  Heineke-Mikulicz  operation  of  pyloroplasty  to  the  treatment  of 
stricture  of  the  ureter,  making  a  longitudinal  incision  over  the  stric- 
tured  portion  and  then  uniting  the  wound  transversely.] 

Ureteral  calculi  are  caused  by  the  descent  of  a  calculus  from  the 
pelvis  of  the  kidney.  They  have  three  points  of  predilection,  namely, 
at  the  junction  of  the  renal  pelvis  and  ureter,  in  the  lower  third  of  the 
ureter  where  the  sacrum  bends  forward,  and  in  the  intravesical  portion 
of  the  ureter. 

The  symptoms  vary  according  as  the  stone  partly  or  completely 
obstructs  the  flow  of  urine.  In  the  latter  instance  typical  renal  colic 
and  anuria  are  not  uncommon,  whereas  in  the  former  no  symptoms 
whatever  may  be  produced.  A  calculus  may  remain  impacted  for 
years. 

If  the  history,  and  symptoms  of  the  case  be  carefully  studied  and  the 
results  of  palpation  and  catheterization  of  the  ureters  be  considered, 
diagnosis  will  not  be  difficult.  If  the  symptoms  persist  extraperito- 
neal ureterectomy  is  the  proper  procedure. 

[The  upper  portion  of  the  ureter  may  be  exposed  by  either  of  the  two 
principal  incisions  described  for  exposing  the  kidney. 

If  the  oblique  incision  be  prolonged  around  the  iliac  crest,  parallel 
with  Poupart's  ligament,  to  a  point  corresponding  to  the  external 
abdominal  ring  (Henry  Morris),  nearly  the  whole  length  of  the  ureter 
can  be  brought  into  view.  The  abdominal  portion  of  this  incision  is 
carried  down  to  the  peritoneum,  which  is  then  separated  and  displaced 
inwards  so  as  to  expose  the  ureter. 

A  longitudinal  incision  is  then  made  in  the  ureter,  the  calculus 
extracted,  and  the  wound  closed  with  catgut.  In  cases  where  the 
ureter  is  greatly  distended  with  foul  decomposed  urine  and  pus  drainage 
is  to  be  employed.] 

Tuberculosis,  according  to  my  experience,  does  not  occur  as  an 
isolated  disease.  The  process  either  descends  from  the  kidney  or 
ascends  from  the  bladder,  the  former  being  its  more  common  mode 
of  propagation.  The  diseased  ureter  is  usually  markedly  thickened, 
and  the  appearance  of  its  vesical  orifice  generally  betrays  its  condition. 


EXAMINATION    AND    DISEASES    OF    THE   URETERS.  563 

The  orifice  is  either  irregular,  as  though  ulcerated,  or  it  is  cedematous 
and  swollen;  in  some  cases  it  is  surrounded,  or  perhaps  occluded,  by 
an  area  of  bullous  oedema.  Attempts  at  catheterization  sometimes  fail 
in  consequence  of  the  changes  which  have  taken  place  in  the  ureter. 
These  consist  in  thickening  of  the  mucous  membrane  (cedema),  stric- 
ture and  kinking.  The  complete  clinical  picture,  the  inemcacy  of 
treatment  directed  to  the  bladder,  and  the  finding  of  tubercle  bacilli 
in  the  urine  make  diagnosis  certain. 

For  further  details  concerning  these  affections  the  reader  is  referred 
to  the  articles  on  the  diseases  with  which  they  are  associated. 


564  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 


FUNCTIONAL  DISTURBANCES  OF  THE  SEXUAL  ORGANS. 

PHYSIOLOGY. 

In  the  male  puberty  begins  at  about  the  fifteenth  year.  The  first 
signs  of  its  development  are  changes  of  voice,  growth  of  hair  on  certain 
parts  of  the  body  (pubes  and  face),  and  awakening  of  the  sexual  im- 
pulse. At  the  same  time,  or  occasionally  before,  erections  of  the 
penis  begin  to  occur;  they  constitute  the  most  essential  attribute  of 
masculine  potency. 

ERECTION. 

Erection  is  under  control  of  the  nervous  system  and  it  may  be  evoked 
by  stimuli  affecting  the  brain,  certain  peripheral  nerves,  and  the  spinal 
cord.  These  nerve-tracts  influencing  erection  have  been  demonstrated 
on  dogs  by  Eckhard.  There  is  no  reason  to  believe  that  the  conditions 
in  man  are  any  different  than  in  the  higher  animals.  According  to 
Eckhard  the  nerves  controlling  erection  originate  in  the  spinal  cord; 
he  succeeded  in  exciting  erections  with  electrical  stimulation  of  the 
cervical  as  well  as  the  lumbar  portion  of  the  cord.  Irritation  of  the 
pons  at  the  point  of  entrance  of  the  crura  cerebri  into  the  cerebrum 
likewise  produced  rigidity  of  the  penis.  From  these  experiments  he 
concluded  that  the  impulses  necessary  for  the  production  of  an  erection 
originate  in  the  cerebrum  and  are  transmitted  through  the  pons  and 
crura  cerebri  to  the  cord. 

Furthermore,  Goltz  found  that  after  separation  of  the  lumbar  portion 
from  the  remainder  of  the  cord,  erections  could  be  produced  by  irritating 
the  glans  penis.  This  led  to  the  conclusion  that  there  is  an  inde- 
pendent center  of  erection  in  the  lumbar  cord. 

Goltz  also  showed  that  this  lumbar  center  may  be  inhibited  by 
impulses  from  the  medulla  and  brain.  He  found  that  reflex  stiffening 
of  the  penis  occurred  much  more  quickly  when  the  cord  was  divided 
between  the  thoracic  and  lumbar  portions,  that  is,  when  the  putative 
inhibitory  influence  of  the  rest  of  the  cord  and  brain  is  eliminated. 

Clinical  observations  in  man  are  in  accord  with  these  statements. 
The  influence  of  the  brain  upon  erection  is  shown  by  the  circumstance 
that    certain   sights    and    mental  impressions  are  quite  sufficient  to 


ANATOMY    AND    PHYSIOLOGY.  565 

produce  an  erection;  indeed,  this  is  the  most  frequent  mode  of  origin; 
the  sight  of  certain  women,  a  lewd  conversation,  obscene  pictures, 
or  even  the  mere  thought  of  such  things,  will  cause  rigidity  of  the  penis. 

That  erections  may  be  generated  in  the  spinal  cord  is  also  proved 
by  clinical  observations.  It  is  known  that  in  the  primary  hypersemic 
stage  of  certain  chronic  diseases  of  the  spinal  cord,  frequent  erections 
or  even  priapism  are  among  the  usual  symptoms.  So,  too,  erection 
and  ejaculation  have  been  observed  in  certain  forms  of  irritation  and 
concussion  of  the  cord,  particularly  in  the  upper  cervical  portion 
(Oliver),  and  in  fractures  and  dislocations  of  the  vertebrae;  they  are 
often  the  first  sign  of  a  beginning  ataxia  (Erb). 

In  regard  to  reflex  stiffening  of  the  penis,  it  is  well-known  that 
friction  or  even  touching  the  organ  may  cause  it  to  become  turgid. 
In  acute  gonorrhoea,  prostatitis,  and  vesical  calculi  frequent  painful 
erections  are  one  of  the  most  constant  symptoms.  They  are  reflex 
and  are  due  to  irritation  of  the  peripheral  nerves  resulting  from  inflam- 
mation in  the  urethra,  prostate,  or  bladder.  The  usual  morning 
erection  is  due  to  irritation  of  the  peripheral  nervi  erigentes  by  a 
distended  bladder. 

In  regard  to  the  phenomenon  of  erection  itself,  it  must  be  admitted 
that  its  mechanism  is  not  perfectly  clear,  although  the  works  of  Kolliker, 
Kohlrausch,  Eckhard,  Goltz,  Loven  and  Frey  have  materially  advanced 
our  knowledge  of  it.  The  existence  of  an  erection  is  dependent 
upon  an  increased  afflux  of  blood  to  the  corpora  cavernosa  and  a 
lessened  outflow  from  the  same,  so  that  they  contain  more  blood 
when  the  penis  is  rigid  than  at  other  times.  It  is  not  entirely  clear, 
however,  in  exactly  what  manner  this  change  in  the  circulation  is 
effected.  That  it  is  entirely  dependent  upon  interference  with 
the  outflow  of  venous  blood  is  doubtless  false,  for  a  good  erection  can- 
not be  produced  by  simply  tying  the  veins  of  the  penis.  There  is  a 
simultaneous  increase  in  the  flow  of  arterial  blood;  in  animals  the 
manometer  shows  a  fall  in  blood-pressure  in  the  arteries  near  the 
penis  during  erection,  and  Eckhard  proved  that  it  extended  to  the 
femoral  artery. 

How  does  this  increased  afflux  of  blood  occur?  It  is  practically 
certain  that  it  is  not  due  to  increased  cardiac  action;  at  least  this  is  a 
very  subordinate  factor  in  the  production  of  the  necessary  afflux  of 
arterial  blood.  It  is  much  more  probable  that  the  arteries  of  the 
penis  are  dilated  during  erection  so  that  more  blood  enters  the  organ. 


566  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

In  answer  to  the  question  as  to  whether  the  vessels  become  dilated 
by  direct  action  of  the  muscle  fibers  in  their  walls,  or  whether  the  walls 
become  relaxed  and  the  caliber  of  the  vessels  thus  increased,  Goltz 
made  the  following  statement:  "I  am  of  the  opinion  that  the  relation 
of  the  nervi  erigentes  to  the  penis  is  the  same  as  that  of  the  vagus  to 
the  heart  or  the  chorda  tympani  to  the  submaxillary  gland.  When 
the  penis  is  flaccid  its  small  arteries,  and  perhaps  other  vascular  spaces 
as  well,  are  in  a  state  of  moderate  contraction,  in  consequence  of  which 
the  blood-current  in  the  penis  is  subjected  to  considerable  pressure. 
It  is  probable  that  this  tonicity  of  the  vessels  is  maintained  by  the 
small  ganglia  which  Loven  discovered  on  the  penis.  Now  when  the 
nervi  erigentes  are  stimulated  to  activity,  the  contracted  arteries  of  the 
penis  relax  and  forthwith  become  dilated  under  the  pressure  of  the 
blood,  which  is  copiously  poured  into  the  retiform  spaces  of  the  corpora 
cavernosa,  distending  them  to  the  utmost.  I  am  inclined  to  agree  with 
Loven  that  the  peripheral  ganglia  in  the  penis  are  the  center  of  vascular 
tonicity  and  believe  that  they  may  be  inhibited  by  the  nervi  erigentes, 
just  as  it  is  supposed  that  the  vagus  inhibits  the  ganglia  of  the  heart." 

Whether  this  explanation  is  true  or  whether  direct  muscular  action 
is  the  cause,  or  whether  both  relaxation  and  muscular  action  are 
responsible,  has  not  yet  been  determined. 

There  is  less  difficulty  in  explaining  how  the  venous  reflux  is  preven- 
ted. Part  of  the  veins  which  carry  the  blood  from  the  corpora  caver- 
nosa empty  into  the  dorsal  vein  of  the  penis  and  the  remainder  pass  to 
the  under  surface  of  the  organ  through  interstices  in  the  cortical  plexus. 
If  the  corpora  cavernosa  are  filled  with  blood,  pressure  of  the  cortical 
plexus  upon  the  veins  will  hinder  the  outflow  of  blood  from  these 
bodies. 

In  addition  to  this  there  is  the  action  of  a  muscular  apparatus  by 
which  the  reflux  of  blood  is  completed.  The  bulbo-cavernosus 
[accelerator  urinae]  arises  from  a  tendinous  raphe,  from  which  the 
transversus  perinei  and  sphincter  ani  externus  also  take  origin.  Its 
fibers  extend  along  both  sides  of  the  bulb  to  bifurcate  above  and  be 
inserted  into  the  fibrous  sheath  of  the  corpora  cavernosa.  When 
this  muscle  contracts  the  penis  is  constricted  in  the  region  of  the  sym- 
physis and  the  return  of  blood  from  the  corpora  cavernosa  thereby 
impeded.  At  the  same  time  the  penis  is  elevated  and  pressed  against 
the  symphysis  by  the  ischio-cavernosus,  which  also  assists  in  prevent- 
ing the  reflux  of  blood  from  the  corpora  cavernosa. 


ANATOMY    AND    PHYSIOLOGY.  567 

COHABITATION    AND    ORGASM. 

Cohabitation  is  a  term  applied  to  the  act  of  copulation,  through 
which  the  sperm  is  implanted  in  the  ovum.  For  the  fulfillment  of 
this  act  rigidity  of  the  penis  is  necessary,  so  that  it  can  be  introduced 
into  the  vagina  of  the  female.  By  friction  upon  the  vaginal  walls 
it  is  so  stimulated  that  orgasm  and  ejaculation  occur,  the  latter  being 
reflex.  Orgasm  is  the  crisis  of  voluptuous  sensation  which  is  experi- 
enced when  the  semen  escapes  through  the  urethra,  or  to  be  more 
exact,  when  it  is  expelled  from  the  ejaculatory  duct  into  the  urethra. 

LIBIDO   SEXUALIS. 

The  sexual  impulse  peculiar  to  the  healthy  adult  male,  and  compar- 
able to  the  sexual  instinct  of  certain  animals,  is  excited  by  those  causes 
which  we  have  recognized  in  the  production  of  erection,  only  they  are 
so  intensified  that  they  impel  the  individual  to  the  performance  of 
the  sexual  act. 

It  is  very  difficult  to  draw  the  line  between  normal  and  abnormal 
sexual  impulse;  it  must  be  remembered  that  the  sexual  feeling  is  not 
so  highly  developed  per  se,  but  that  it  is  rather  aroused  by  occasional 
causes.  It  is  generally  greater  in  men  than  in  women.  It  is  also 
influenced  by  individual  disposition,  regimen  of  living,  food  and 
occupation.  Persons  who  work  little  and  eat  heartily  of  stimulating 
food  are  much  disposed  to  eruptions  of  the  sexual  feeling,  while  those 
who  are  engaged  in  mental  or  physical  work  find  that  their  passions 
are  kept  subdued. 

EJACULATION. 

Ejaculation  is  the  term  applied  to  the  reflex  process  by  which  semen 
is  discharged  into  the  urethra  and  carried  out  of  the  body.  When  the 
crisis  of  sexual  excitement  is  reached  the  musculature  of  the  seminal 
vesicles  and  ejaculatory  ducts  force  the  semen  into  the  urethra,  whence 
it  is  forcibly  ejected  by  a  spasmodic  contraction  of  the  bulbo-cavernosus 
and  the  sphincteric  portion  of  the  prostate  [sphincter  vesicae].  Ejacu- 
lation is  under  the  influence  of  reflex  excitation  of  the  ejaculatory 
center  (genito-spinal  center  of  Budge),  which  lies  in  the  cord  on  the 
level  of  the  fourth  lumbar  vertebra.  This  center  sends  fibers  to  the 
bulbo-cavernosus,  which  accordingly  is  the  true  muscle  of  ejaculation. 


568  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

THE  SEMEN. 

By  semen  or  sperm  is  meant  the  fluid  which  under  normal  conditions 
flows  out  of  the  male  urethra  at  the  termination  of  coition.  This 
fluid  is  not  a  simple  product,  but  is  composed  of  the  secretion  of  the 
testicles,  vasa  deferentia,  seminal  vesicles,  prostate  and  mucous  glands 
of  the  urethra. 

The  testicular  secretion  as  it  is  found  in  the  seminiferous  tubules 
is  a  thick,  white,  viscid  mass,  consisting  principally  of  spermatoblasts, 
the  mother-cells  of  spermatozoa.  The  spermatozoa  are  first  seen  in 
the  rete  Halleri.  Here  and  in  the  following  segment  of  the  seminal 
passage,  in  the  epididymis  and  vas  deferens,  they  are  non-motile,  in 
consequence,  no  doubt,  of  the  density  of  the  surrounding  medium, 
which  is  a  tenacious  fluid  containing  nucleated  epithelial  cells  of 
various  shapes,  and  irregular,  highly  refractive  granular  cells.  In  the 
vasa  deferentia  the  spermatozoa  become  thoroughly  mixed  with  this 
fluid  and  are  carried  to  the  seminal  vesicles  with  it. 

The  secretion  of  the  seminal  vesicles  which  is  now  added  to  the  mix- 
ture is  tenacious,  odorless  and  colorless,  of  a  higher  specific  gravity 
than  water,  neutral  in  reaction  and  non-coagulable.  It  contains 
nucleated  polyhedral  epithelium,  isolated  leucocytes  and  shiny  bodies 
resembling  grains  of  sago. 

The  secretion  of  the  prostate  is  also  added  to  the  semen.  It  is 
alkaline  or  neutral  and  of  a  milky,  opalescent  color;  it  contains  very 
fine  granular  cells,  droplets  of  lecithin  and  hyaline  flakes,  to  which 
isolated  epithelial  cells  are  almost  always  added  when  the  prostatic 
secretion  is  expressed  by  pressure  through  the  rectum.  It  is  this 
secretion  which  gives  the  semen  its  white,  half  translucent,  opalescent 
property,  which  differentiates  it  from  the  secretion  found  in  the  seminal 
vesicles.  If  several  ejaculations  occur  in  succession,  the  opalescence 
of  the  semen  becomes  less  and  less;  it  becomes  thinner  and  more  like 
the  contents  of  the  seminal  vesicles.  This  is  due  to  the  absence  of 
prostatic  fluid. 

Occasionally  the  so-called  prostatic  corpuscles,  stratified  bodies 
having  an  amber  or  brown  center  usually  surrounded  by  light  concen- 
tric layers,  are  found  in  the  prostatic  fluid.  These  corpuscles  vary  in 
size  from  minute  specks  to  masses  as  large  as  a  hemp-seed.  They  are 
colored  blue  by  iodine  and  green  by  substances  rich  in  albumen. 

The  next  ingredient  added  to  the  seminal  fluid  is  the  secretion  from 
Cowper's  glands,  a  tenacious,  ropy,  hyaline  mass  which  is  alkaline 


ANATOMY    AND    PHYSIOLOGY.  569 

in  reaction  and  serves  to  lubricate  the  parts  with  which  it  comes  in 
contact.  It  is  secreted  during  erection,  at  the  moment  of  ejaculation, 
and  is  analogous  to  the  secretion  of  Bartholin's  glands  in  the  female. 
Let  us  now  consider  the  semen  as  a  whole,  as  it  appears  after  an 
emission.  It  is  a  tenacious,  grayish,  opalescent  fluid  of  alkaline  reac- 
tion having  a  higher  specific  gravity  than  water  and  a  peculiar  odor 
resembling  that  of  boiled  starch.  The  quantity  discharged  at  a  single 
emission  varies  in  different  men  from  5  to  20  g.  [i1  to  5  fl.  drachms]. 


Fig.  228. — Normal  Semen,     a.  Spermatozoa,     b.  Molecular  detritus,      c.  Sper- 
matoblasts,    d.  Leucocytes,     e.  Epithelium.     /.  Specks  of  pigment. 


If  coitus  is  repeated  at  frequent  intervals,  the  quantity  decreases  with 
each  ejaculation  until  finally  only  a  few  drops  are  expelled. 

Immediately  after  it  is  voided  the  seminal  fluid  becomes  converted 
into  a  gelatinous  mass,  although  the  air  soon  causes  it  to  liquefy  again. 
According  to  Vauquelin  it  is  composed  of  10%  of  solids  and  90%  of 
water.  One-half  of  the  solids  are  organic  elements.  An  albuminoid 
substance  called  spermatin  can  be  extracted  from  the  semen;  it  is 
probably  formed  in  the  seminal  vesicles.     About  3%  of  the  solid 


570  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

elements  is  phosphate  of  lime,  and  i%  sodium  salts;  traces  of  ammonio- 
magnesium  phosphate  are  also  found. 

If  a  drop  of  seminal  fluid  is  examined  under  the  microscope  all  these 
elements  are  found  (Fig.  228). 

The  most  important  and  most  striking  are  the  actively  motile, 
undulating  spermatozoa.  Not  always,  though  occasionally,  leucocytes, 
the  concentric  stratified  prostatic  corpuscles,  and  the  sago-like  particles 
known  as  Lallemand-Trousseau  corpuscles  are  found.  The  fecundat- 
ing power  of  the  semen  depends  upon  the  life  of  the  spermatozoa. 
The  only  sure  sign  of  their  vitality  that  we  yet  possess  is  their 
motility. 

If  semen  is  allowed  to  stand  in  a  reagent  glass  for  a  few  hours,  it 
separates  into  two  layers,  the  upper  of  which  is  thin,  white  and  trans- 
lucent, somewhat  resembling  whey,  while  the  lower  is  a  thick,  white, 
opalescent  mass.  If  a  drop  of  the  upper  layer  be  examined  micro- 
scopically, it  will  be  found  to  contain  epithelium  and  molecular  detritus 
(the  seminal  granules) ;  the  under  stratum  is  composed  of  spermatozoa. 
From  the  thickness  of  this  layer  and  the  rapidity  with  which  it  forms 
an  idea  as  to  the  quantity  of  spermatozoa  in  a  given  specimen  of 
semen  can  be  obtained   (Ultzmann). 

In  normal  semen  their  number  is  very  great,  many  thousands  being 
contained  in  one  drop.  Under  the  microscope  they  are  seen  to  be 
actively  motile.  They  consist  of  a  flattened  pyriform  head,  a  neck  and 
a  long  thread-like  tapering  tail.  The  tail  is  from  ten  to  twelve  times 
as  long  as  the  head  and  makes  incessant  undulating,  lashing  move- 
ments, by  which  the  head  is  pushed  forward  between  other  sperma- 
tozoa and  cells.  This  vivacity  of  movement  caused  the  spermatozoa 
to  be  called  seminal  animalcules.  The  semen  soon  dries  under  a  cover 
glass  and  the  most  active  spermatozoa  lose  their  power  of  motion  after 
a  few  hours;  if  the  semen  be  guarded  from  light  and  cold,  however, 
living  spermatozoa  may  be  found  at  the  expiration  of  thirty-six  or 
forty-eight  hours.  Dead  spermatozoa  differ  in  no  wise  from  the 
living  except  that  their  tail  is  extended  or  its  extremity  perhaps  coiled 
up  in  spiral  form. 

Water  destroys  spermatozoa  immediately,  whereas  normal  saline 
solution  prolongs  their  power  of  motility  for  some  time ;  alkalies,  such 
as  solutions  of  potassium  and  sodium,  also  favor  their  motility,  whereas 
acids,  metal  salts,  and  acid  secretions,  as  urine,  for  example,  at  once 
kill  them. 


ANATOMY   AND    PHYSIOLOGY.  57 1 

This  leads  us  to  consider  the  significance  and  importance  of  the  differ- 
ent components  of  the  semen.  As  some  urine  remains  in  the  urethra 
after  each  act  of  micturition,  and  as  the  semen  passes  through  this 
canal,  its  contact  with  the  acid  urethral  walls  would  impair  the  vitality 
of  the  spermatozoa  had  not  nature  provided  a  means  to  prevent  this 
evil.  The  remedy  is  provided  by  the  secretion  of  the  prostate,  Cowper's 
glands,  the  urethral  mucous  glands  and  the  sinus  pocularis.  During 
erection  and  at  the  moment  of  ejaculation  the  last  three  secrete  an 
alkaline  fluid  which  greases,  lubricates,  and  makes  the  urethral  wall 
alkaline. 

It  has  already  been  stated  that  the  secretion  of  the  seminal  vesicles 
acts  chiefly  as  a  diluent  of  the  testicular  product  and  thereby  causes 
the  spermatozoa,  which  are  previously  motionless,  to  become  motile. 

The  prostatic  fluid  is  of  equal  importance.  Marris  Wilson  long 
since  showed  that  the  secretion  of  the  prostate  is  necessary  to  maintain 
the  vitality  of  the  spermatozoa.  He  believed  that  it  was  the  neutral 
phosphate  of  lime  in  this  fluid  which  preserved  them  from  the  destruc- 
tion to  which  they  would  be  subjected  by  contact  with  the  acid  secre- 
tions of  the  urethra. 

Percy  proved  that  spermatozoa  soon  perish  in  the  uterine  secretions 
unless  the  latter  are  mixed  with  prostatic  fluid;  when  prostatic  fluid  is 
present,  however,  they  remain  active  for  three,  four  or  even  eight 
days.  More  recent  investigations  have  confirmed  this  view.  Fiir- 
bringer,  who  by  the  way  believes  the  prostatic  fluid  to  be  acid,  added 
fresh  prostatic  secretion  to  the  semen  of  a  man  affected  with  spermator- 
rhoea and  found  that  previously  sluggish  spermatozoa  became  active; 
he  therefore  concluded  that  the  prostatic  secretion  exerts  a  specific 
vitalizing  action  upon  the  spermatozoa  which  are  dormant  while  in  the 
seminal  vesicles  and  spermatic  ducts. 

The  relation  of  the  prostatic  secretion  to  the  power  of  impregnation 
is  shown  by  another  observation,  if  not  with  certainty  at  least  with 
probability. 

If  semen  is  dried  on  a  glass  slide  and  examined  after  a  certain  time, 
varying  from  a  few  hours  to  three  days,  peculiar  crystals  having  the 
form  of  rhombic  prisms  and  ending  in  fine  points  or  rhomboid  margins, 
are  found  lying  alone  or  arranged  in  layers.  If  one  of  these  plates 
lies  upon  another  a  cross  is  formed,  and  if  several  are  placed  across 
each  other  a  rosette  is  produced  (Fig.  229).  The  composition  and 
significance  of  these  crystals,  which  were  described  by  Van  Deen  and 


572  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

Bottcher,  and  named  after  the  latter  Bottcher's  spermatic  crystals,  is 
still  a  subject  of  dispute. 

Bottcher  thinks  that  they  are  albuminoid  bodies,  Schreiner  consid- 
ers them  to  be  phosphatic  salts  having  an  organic  base,  Ultzmann  be- 
lieves that  they  are  composed  of  phosphate  of  magnesium,  and  Gross 
that  they  are  made  up  of  ammonio-magnesium  phosphate.  Others 
believe  them  to  be  identical  with  Charcot's  crystals,  which  are  said 
to  occur  wherever  profuse  mucous  secretion  exists.    Fiirbringer  proved 


Fig.  229. — Spermatic  crystals. 

by  examination  of  the  contents  of  the  seminal  vesicles  and  the  pros- 
tatic secretion  of  a  large  number  of  corpses,  and  also  the  prostatic 
fluid  of  the  living,  that  these  crystals  are  found  only  in  the  prostatic 
fluid.  He  attributes  the  peculiar  smell  of  the  semen  to  these  bodies. 
It  is  certain  that  they  do  not  originate  in  the  testicular  secretion,  for 
they  are  found  most  abundantly  and  best  developed  in  azoospermia,  a 
condition  in  which  spermatozoa,  the  characteristic  element  of  the 
testicular  secretion,  are  absent. 

It  may  be  said  that  the  relation  of  the  spermatozoa  to  the  spermatic 
crystals  is  one  of  inverse  proportion;  the  more  numerous  the  latter 
and  the  more   quickly  they  are  formed,  the  fewer  the  spermatozoa 


THE    ABNORMAL   LOSS    OF    SEMEN.  573 

or  the  less  their  activity.  Therefore  they  are  almost  always  found  in 
azoospermia.  The  thinner  and  poorer  in  spermatozoa  the  semen, 
the  earlier  the  appearance  of  these  crystals  and  the  greater  their  number. 

While  they  are  found  in  normal  semen  only  when  it  has  been  dried, 
and  then  perhaps  only  after  several  days,  in  the  semen*  of  azoospermia 
they  are  seen  a  few  hours  after  ejaculation.  A  drop  of  i%  solution 
of  ammonium  phosphate  renders  them  more  distinct  (Fiirb ringer). 
Ultzmann  explains  the  late  occurrence  of  these  crystals  in  normal 
semen  by  assuming  that  crystallization  cannot  take  place  in  a  fluid  so 
full  of  motion.  It  is  only  after  the  spermatozoa  die  and  the  semen 
becomes  still  that  crystallization  can  begin. 

According  to  these  statements  the  presence  of  spermatic  crystals 
is  of  value  in  determining  the  impregnating  power  of  the  semen. 

The  time  at  which  semen  is  produced  varies  in  different  persons. 

Generally  speaking  it  begins  to  be  secreted  at  puberty  and  may 
continue  until  an  advanced  age.  Liegeois  found  spermatozoa  in  the 
semen  of  two  boys  of  fourteen,  four  of  sixteen  and  two  of  eighteen 
years.  In  respect  to  the  age  limit,  it  may  be  stated  that  Wagner  found 
them  in  the  semen  of  men  sixty  and  seventy  years  old,  Curling  in  that 
of  a  man  aged  eighty-seven,  and  Casper  (the  medico-legal  expert)  in 
that  of  one  aged  ninety-six.  Out  of  twenty-three  cases  in  which  death 
resulted  from  the  weakness  of  old  age  or  from  affections  common  to 
this  period  of  life,  and  in  which  no  serious  organic  lesions  were  present, 
Dieu  found  them  six  times.  Therefore  it  is  seen  that  semen  capable 
of  causing  impregnation  may  be  produced  under  normal  physiological 
conditions  until  an  advanced  age,  but  that  its  fecundating  power  dies 
out  under  the  influence  of  severe  diseases  and  a  high  degree  of  cachexia. 

FUNCTIONAL  DISEASES  OF  THE  SEXUAL  ORGANS. 

Having  discussed  the  physiology  of  the  sexual  apparatus  we  will  now 
consider  its  functional  disturbances.  We  will  first  study  the  so-called 
abnormal  loss  of  semen,  secondly  impotence,  and  thirdly  sterility. 

THE  ABNORMAL  LOSS  OF  SEMEN. 

Under  normal  conditions  the  adult  male  loses  semen  only  upon 
cohabitation,  or  if  this  is  not  indulged  in  for  a  long  time,  it  escapes 
spontaneously  at  intervals,  this  loss  constituting  what  is  known  as 
pollutions.     The  occurrence  of  pollutions  is  somewhat  physiologic. 


574  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

They  take  place  during  sleep  and  are  usually  accompanied  by  lascivious 
dreams  and  a  sense  of  erection.  They  are  due  to  irritation  produced 
by  distention  of  the  seminal  vesicles  with  semen;  this  irritation  is 
transmitted  by  sensory  nerve  fibers  to  the  spinal  cord,  especially  to  the 
ejaculatory  center,  and  when  its  maximum  is  attained  it  sets  up  a 
reflex  contraction  of  the  seminal  vesicles  and  vasa  deferentia. 

Accordingly  pollutions  are  most  common  in  the  bloom  of  sexual  life, 
when  the  semen  is  most  abundantly  produced.  Physiological  pol- 
lutions are  not  characterized  so  much  by  the  frequency  of  their  occur- 
rence as  by  the  manner  in  which  they  take  place.  If  a  strong 
young  man  who  lives  on  rich  food  has  an  emission  about  once  a  week 
without  any  bad  reaction  on  his  health,  it  is  to  be  considered  entirely 
physiological. 

The  production  of  semen,  and  therefore  its  evacuation,  varies  in 
different  persons ;  it  is  greater  in  those  who  lead  an  active  sexual  lif e, 
whose  mind  is  occupied  with  sexual  matters,  than  in  those  who  live 
moderately  and  engage  in  active  mental  pursuits.  In  the  first  class 
the  increased  production  of  semen  {plethora  seminalis),  inconsequence 
of  the  reflex  action  produced  by  distention  of  the  seminal  vesicles, 
leads  to  frequent  desire  to  empty  these  organs  and  to  increased  irri- 
tability of  the  ejaculatory  apparatus. 

Nocturnal  pollutions,  then,  become  pathologic  only  when  they  exert 
a  bad  reaction  upon  the  general  health.  They  are  pathologic  when 
they  occur  with  undue  frequency,  as  for  example,  on  several  nights 
in  succession  or  several  times  in  one  night,  and  when  the  characteristic 
accompaniments,  erection  and  voluptuous  feeling,  are  absent  or 
considerably  diminished.  The  patients  feel  weak  and  debilitated, 
are  tired,  disinclined  to  work,  and  morose  or  irritable.  Pollutions 
having  such  after  effects  are  naturally  pathologic. 

Pollutions  occurring  during  the  day  and  resulting,  as  is  usually  the 
case,  from  slight  mechanical  or  psychical  irritation,  are  to  be  considered 
as  a  symptom  of  disease.  It  must  be  borne  in  mind  that  abnormal 
pollutions  do  not  constitute  a  disease,  but  that  they  are  only  a  symptom 
of  some  morbid  condition.  If  a  loss  of  semen  occurs  without  volup- 
tuous feeling,  without  orgasm,  without  erection,  the  fluid  escaping 
gradually  instead  of  being  forcibly  ejected,  the  condition  is  then 
known  as  spermatorrhoea. 

This  spontaneous  and  persistent  loss  of  semen  is  very  rare.  It 
generally  follows  defecation  and  micturition. 


THE    ABNORMAL    LOSS    OF    SEMEN.  575 

If  morbid  pollutions  are  considered  as  due  to  a  motor  neurosis 
of  the  sexual  apparatus,  a  spasm  of  the  musculature  of  the  seminal 
vesicles,  then  spermatorrhoea  represents  a  paresis  of  the  ejaculatory 
ducts.  It  is  conceivable  that  there  may  be  various  transitional  forms 
between  pollutions  and  spermatorrhoea;  thus,  for  instance,  pollutions 
may  be  associated  with  imperfect  erections,  and  there  are  cases  of 
spermatorrhoea  in  which  slight  rigidity  of  the  penis  supervenes,  together 
with  some  pleasurable  sensation. 

In  order  to  understand  the  significance  of  pathologic  pollutions 
and  spermatorrhoea  it  is  essential  to  know  from  what  causes  they 
arise  and  in  what  diseases  they  occur. 

Both  occur  in  neurasthenia,  a  disease  of  most  diverse  manifesta- 
tions, but  which  will  be  considered  here  only  in  its  relation  to  the 
sexual  system.  In  this  disease  there  is  an  hereditary  or  acquired 
debility  of  the  entire  nervous  system,  a  nervous  cachexia,  so  to  speak. 
The  nervous  system's  power  of  resistance,  especially  that  of  the  affected 
centers,  is  so  slight  that  the  most  trivial  stimulation  produces  the 
maximum  of  irritability,  as  the  result  of  which  ejaculation  ensues; 
or,  conversely,  the  normal  tonicity  of  the  ejaculatory  duct  is  raised  to 
the  highest  point,  so  that  the  semen  flows  away  spontaneously  or  escapes 
upon  the  slightest  pressure. 

Thus,  sexual  excesses  may  cause  this  symptom,  either  directly  or  by 
inducing  neurasthenia.  Of  the  sexual  excesses  masturbation  occupies 
the  first  rank;  it  is  immaterial  whether  it  be  physical,  that  is,  practised 
by  frictioning  the  penis,  or  only  psychical,  an  ejaculation  being  induced 
by  conjuring  up  voluptuous  fancies. 

At  present  we  do  -not  believe  in  the  dreadful  results  of  masturbation 
described  by  Lallemand  and  Tissot,  but  yet  it  must  be  conceded  that 
if  the  habit  is  persisted  in  for  years  it  will  impair  the  soundness  of  both 
body  and  mind,  that  it  will  result  in  enfeeblement  and  hyperesthesia 
of  the  nervous  system.  It  is  not  so  much  the  numerous  losses  of  semen 
as  it  is  the  effect  of  the  frequently  repeated  stimulation  upon  the 
nervous  system  which  brings  about  this  condition.  The  frequency 
with  which  masturbation  is  practised  explains  why  abnormal  pollutions 
result  more  frequently  from  this  habit  than  from  sexual  excesses. 

That  coitus  interruptus,  or  coition  terminated  before  its  completion, 
for  the  purpose  of  preventing  conception,  may  cause  spermatorrhoea 
if  it  be  persisted  in  for  years,  is  no  doubt  correct,  although  such  a  result 
is  exceptional.     I  have  seen  a  general  nervous  condition  follow  this 


576  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

practice  much  more  frequently  than  the  symptoms  now  under  dis- 
cussion. 

The  same  is  true  of  sexual  abstinence.  It  is  true  that  men  who 
have  been  accustomed  to  regular  sexual  intercourse,  but  have  been 
forced  by  circumstances  to  become  continent,  have  frequent  pollutions, 
although  these  emissions  are  not  pathologic  because  they  have  no 
injurious  reaction.  They  are  rather  an  effort  of  nature  to  relieve 
seminal  plethora. 

All  the  etiologic  factors  which  have  been  mentioned  do  not  cause 
pollutions  and  spermatorrhoea  as  often  as  they  produce  certain  local 
affections  of  the  urinary  and  sexual  organs:  chronic  urethritis,  which 
has  extended  to  the  ejaculatory  ducts,  and  chronic  inflammation  of  the 
seminal  vesicles  and  prostate  are  conditions  which  I  have  frequently 
found  in  cases  of  abnormal  loss  of  semen.  If  the  former  can  be  cured 
the  latter  will  usually  subside.  It  is  in  these  cases  that  loss  of  semen 
during  or  immediately  after  defecation  or  micturition  is  the  most 
common. 

Finally,  frequent  pollutions  may  occur  in  certain  organic  diseases 
of  the  spinal  cord,  in  the  early  stages  of  tabes  and  myelitis,  for  instance. 

The  diagnosis  of  pollutions  and  spermatorrhoea  is  usually  readily 
made  from  the  statements  of  the  patient,  although  it  must  be  remem- 
bered that  there  are  discharges  from  the  urethra  which  resemble  semen 
and  may  be  mistaken  for  such  by  the  patient.  These  are  the  dis- 
charges occurring  in  prostatorrhcea  and  urethrorrhcea.  As  they  are 
far  less  important  than  spermatorrhoea  it  is  necessary  to  distinguish 
them  from  the  latter  disease,  which  is  easily  done  by  examining  a  drop 
of  the  discharge  with  the  microscope. 

The  characteristic  picture  of  a  drop  of  semen  has  already  been  des- 
cribed. Prostatorrhcea  shows  the  characteristics  of  prostatic  fluid, 
namely,  lecithin  corpuscles,  small  refractive  specks,  rings  and  flakes, 
epithelial  cells,  and  a  varying  number  of  leucocytes  if  prostatitis  is 
present.     Rarely  stratified  corpuscles  are  found. 

In  urethrorrhcea  only  a  few  leucocytes  and  pavement  and  cylindric 
epithelium  from  the  urethral  glands,  together  with  long  slender  shreds 
of  mucus  are  seen.     Lecithin  corpuscles  and  spermatozoa  are  absent. 

Urethrorrhcea  has  no  pathologic  significance.  It  occurs  in  highly 
sensitive  persons  when  an  afflux  of  blood  to  the  penis  causes  a  partial 
erection  and  forces  the  secretion  of  the  urethral  glands  out  into  the 
urethra. 


SEXUAL    NEURASTHENIA.  577 

Prostatorrhoea  is  often  a  sequel  of  prostatitis.  The  excretory  ducts 
of  the  prostate  are  rigid  and  have  lost  their  tonicity,  so  that  slight 
pressure  exerted  by  scybalous  masses  suffices  to  press  the  prostatic 
secretion  into  the  urethra,  through  which  it  passes  to  the  external 
meatus. 

In  regard  to  the  significance  of  abnormal  pollutions  and  spermator- 
rhoea, it  has  already  been  stated  that  they  do  not  represent  independent 
diseases,  but  that  they  are  a  single  member  of  a  complex  group  of 
symptoms  which  owe  their  existence  to  the  conditions  previously 
enumerated.  They  may  be  symptoms  of  general  neurasthenia,  which 
is  called  sexual  neurasthenia  when  it  chiefly  affects  the  genital  organs ; 
or  in  consequence  of  the  reaction  which  they  produce  they  lead  to 
this  disease  of  the  nervous  system.  A  knowledge  of  them  is  of  the 
greatest  importance  and  therefore  we  will  consider  them  more  in  detail, 
following  for  the  most  part  Krafft-Ebing's  views. 

SEXUAL    NEURASTHENIA. 

Sexual  neurasthenia  is  one  of  those  forms  of  nervous  weakness 
which  express  themselves  as  functional  disturbances  of  the  genitalia. 
These  may  be  the  only  symptoms  of  disease,  although,  as  a  rule,  a 
multitude  of  others  are  present.  Krafft-Ebing  has  analyzed  the  symp- 
tom-complex and  given  us  a  better  understanding  of  it. 

He  recognizes  three  stages  of  the  disease: 

1.  A  local  neurosis  of  the  genitalia,  causing  frequent  pollutions 
and  premature  ejaculations.  2.  A  neurosis  of  the  lumbar  cord,  char- 
acterized by  neuralgia  of  the  lumbo-sacral  plexus,  frequent  nocturnal 
emissions,  diurnal  pollutions  and  impairment  of  sexual  vigor. 
3.  Cerebro-spinal  neurasthenia,  in  which  the  disease  has  advanced  to 
general  neurasthenia. 

Not  all  cases  of  sexual  neurasthenia,  however,  pass  through  these 
typical  stages.  Thus,  for  example,  there  are  cases  of  general  neuras- 
thenia which  have  been  preceded  by  sexual  excesses  or  local  sexual 
neurasthenia.  Severe  general  neuroses  may  result  from  sexual  excesses 
without  involvement  of  the  genital  apparatus,  or  the  most  violent 
sexual  debauchery  may  produce  only  local  disturbances,  no  symptoms 
referable  to  the  cord  and  brain  being  present.  In  this  respect,  too, 
there  are  many  variations  and  combinations.  In  general  it  may  be 
stated  that  masturbation  is  more  prone  to  produce  cerebral  neuras* 
39 


578  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

thenia,  while  excessive  sexual  intercourse  tends  rather  to  cause  the 
spinal  form. 

The  symptoms  of  sexual  neurasthenia  consist  in  cerebral  manifes- 
tations, or  sexual  cerebrasthenia;  in  spinal  manifestations,  or  sexual 
myelasthenia ;  in  lumbar  and  local  genital  manifestations;  and,  finally, 
in  circulatory  and  digestive  disturbances. 

As  cerebral  manifestations  we  recognize  dizziness  and  a  feeling 
of  oppression  which  may  amount  to  violent  headache,  conditions 
which  are  detrimental  to  the  development  of  mental  activity.  The 
patients  cannot  work  as  they  formerly  could  nor  apply  themselves 
continuously  to  labor;  they  begin  to  sleep  poorly  and  become  more  or 
less  ill-tempered  and  irritable.  They  are  fully  aware  of  their  mental 
apathy  and  want  of  energy,  and  this  knowledge  increases  their  moodi- 
ness, so  that  they  may  become  confirmed  hypochondriacs.  They 
cannot  concentrate  their  mind  upon  one  subject.  Weakness  of 
memory  and  sensory  disturbances  supervene;  the  latter  consist  of 
increased  sensibility  to  light,  weakness  of  vision  (asthenopia  neuras- 
thenica),  tinnitus  aurium,  auditory  hyperesthesia  and  disturbances  of 
speech.     Melancholia  as  well  as  hypochondria  may  ensue. 

The  spinal  manifestations  of  neurasthenia,  or  sexual  myelas- 
thenia, usually  occur  in  association  "with  cerebral  neurasthenia,  just 
as  the  latter  is  frequently  accompanied  by  spinal  symptoms.  The 
spinal  symptoms  are  weakness  and  fatigue  upon  walking,  pain  over 
the  back,  loins  and  extremities,  paresthesia  in  these  parts,  a  sensation 
of  itching,  coldness  and  numbness  of  the  legs,  together  with  a  feeling 
of  weight  and  heaviness.  Lancinating  pains  like  those  of  tabes  also 
sometimes  occur.  The  objective  symptoms  of  spinal  irritation  are 
observed,  namely,  localized  sensitive  areas  in  the  spinal  column, 
fibrillary  spasm  of  the  fingers,  tremor  of  the  extremities  and  exaggerated 
patellar  reflex. 

The  local  manifestations  of  sexual  neurasthenia  affect  both  the 
urinary  and  sexual  organs.  Pain  over  the  bladder  before  and  after 
micturition,  urgency  of  urination  and  dribbling  of  urine  are  complained 
of,  although  the  urine  itself  is  found  absolutely  normal.  These 
symptoms  are  due  in  part  to  increased  irritability  of  the  detrusor  and 
in  part  to  diminished  tonicity  of  the  sphincter. 

The  disturbances  of  the  sexual  organs  consist  of  pain  in  the  testicles 
and  epididymes,  hyperesthesia  of  the  glans  penis,  and  occasionally 
involuntary   contractions   of  the   cremasters,    causing   a  jumping  or 


SEXUAL    NEURASTHENIA.  579 

dancing  of  the  testicles,  to  which  the  Germans  have  given  the  name 
Hodentanz.  Abnormal  losses  of  semen  also  take  place,  and  according 
to  the  frequency  with  which  they  occur  may  lead  to  weakness  and 
exhaustion  or  result  in  spermatorrhoea. 

Finally  the  disturbances  of  the  circulatory  and  digestive  systems 
have  to  be  considered.  Among  the  well-recognized  neuroses  of  the 
heart  are  stenocardia,  palpitation,  tachycardia,  pseudo-angina,  pain 
radiating  from  the  cardiac  region  to  the  scapula  and  accompanied 
by  a.  feeling  of  oppression,  and  increased  cardiac  action  after  exertion, 
excitement  and  the  use  of  strong  drink.  The  objective  signs  of  organic 
heart  disease  are  absent. 

The  digestive  tract  is  in  a  condition  of  nervous  dyspepsia.  After 
each  meal  a  feeling  of  pressure  and  pain  develops  in  the  region  of  the 
stomach,  and  retching  or  even  vomiting  may  also  be  present.  It  is 
characteristic  of  this  condition  that  the  patients  sometimes  experience 
violent  pain  in  the  stomach  after  partaking  of  small  quantities  of  easily 
digestible  food,  while  at  other  times  they  can  eat  a  good  dinner  of 
heavy  food  without  feeling  the  worse  for  it. 

Less  commonly  nervous  cardialgia,  irregular  attacks  of  vomiting  and 
gastralgia,  peristaltic  agitation  of  the  stomach  and  intestines,  distention 
of  the  abdomen  and  constipation  are  present.  Both  palpation  and 
examination  of  the  stomach  contents  give  negative  results.  It  is  well- 
known  to  what  extent  this  nervous  dyspepsia  may  produce  disturbances 
of  nutrition  and  thus  simulate  severe  organic  disease  of  the  digestive 
tract. 

The  prognosis  of  abnormal  losses  of  semen  and  sexual  neurasthenia 
is  not  so  unfavorable  as  the  patients  themselves,  and  many  physicians 
as  well,  are  inclined  to  consider  it.  My  experience  leads  me  to  believe 
that  nocturnal  pollutions  and  loss  of  semen  during  defecation  usually 
subside  under  appropriate  treatment,  while  losses  occurring  during 
micturition,  and  diurnal  emissions  occurring  without  any  exciting 
cause  are  difficult  to  influence. 

If  the  condition  is  due  entirely  to  natural  sexual  excesses  the  prognosis 
is  good  if  a  more  moderate  regimen  of  living  is  adopted.  Pollutions 
due  to  local  disease  of  the  sexual  organs  can  also  frequently  be  improved 
or  cured.  Cases  due  to  masturbation  are  difficult  to  help  because  the 
patients  cannot  relinquish  their  bad  habit,  or  if  they  do  give  it  up  for 
a  time,  fall  into  it  again.  The  most  unfavorable  cases  of  all  are  those 
in  which  there  is  an  hereditary  neurotic  taint.     The  duration  of  the 


580  FUNCTIONAL   DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

disease  is  always  considerable.  It  requires  many  months,  or  perhaps 
years,  to  put  these  patients  in  order. 

The  treatment  is  to  be  directed  partly  to  removal  of  the  cause  and 
partly  to  relief  of  symptoms,  although  the  former  is  naturally  the 
more  important. 

As  masturbation  plays  a  role,  even  though  it  be  not  a  great  one, 
in  the  etiology  of  the  disease,  all  possible  means  should  be  taken  to 
guard  against  this  evil.  As  far  as  children  are  concerned  the  task  of 
preventing  its  acquirement  devolves  upon  parents  .and  teachers  rather 
than  upon  the  physician,  although  the  latter  may  be  of  assistance 
by  vouchsafing  proper  advice.  The  appropriate  means  of  prevention 
consists  in  careful  observation  of  the  child,  the  avoidance  of  obscene 
literature,  care  in  the  selection  of  his  companions — as  the  habit  is  fre- 
quently taught  by  others — avoidance  of  arduous  mental  application, 
and  encouragement  in  the  practice  of  physical  exercises  such  as  gym- 
nastics, swimming,  riding,  fencing  and  gardening. 

For  older  persons,  be  they  married  or  unmarried,  who  have  continued 
to  practise  this  vicious  habit,  it  is  first  of  all  necessary  to  make  them 
understand  that  the  evil  results  are  generally  exaggerated.  This 
may  keep  them  from  becoming  neurasthenic  or  hypochondriacal.  As 
much  exercise  and  physical  labor  as  possible,  with  a  light,  easily 
digestible  diet  are  indicated. 

Patients  who  have  acquired  their  disease  by  overindulgence  in 
sexual  intercourse  do  not  require  much  counsel;  they  have  generally 
become  sensible,  their  condition  forcing  them  to  lead  a  different  life. 
It  is  important,  however,  to  make  them  understand  that  the  evil  results 
of  their  excesses,  for  example  spermatorrhoea,  are  of  no  great  signifi- 
cance and  are  of  only  temporary  duration. 

If  an  organic  disease  such  as  tabes  or  myelitis  is  the  cause,  the  mani- 
festations of  the  general  disease  are  so  much  more  pronounced  than 
the  local  symptoms  that  treatment  of  the  latter  may  not  be  indicated. 
The  local  disturbances,  however,  may  annoy  the  patient  very  much 
and  therefore  they  must  be  watched. 

The  bromides,  cold  affusions  to  the  back  and  genitals,  and  galvani- 
zation and  faradization  of  the  spinal  cord  are  the  appropriate  remedies. 
The  results  are  slight  and  seldom  permanent.  Relapses  require 
treatment. 

The  prospects  of  improvement  and  cure  are  best  in  those  cases  of 
frequent  abnormal  pollutions  and  spermatorrhoea  dependent  upon  a 


SEXUAL    NEURASTHENIA.  581 

localized  lesion  in  the  sexual  organs.  Of  such  lesions  by  far  the  most 
common  are  those  due  to  chronic  gonorrhoea,  which  almost  always 
extends  to  the  posterior  urethra  and  invades  the  prostate  and  seminal 
vesicles.  The  measures  recommended  for  chronic  gonorrhoea 
(quod  vide)  may  be  used  with  advantage  in  this  condition,  according  to 
the  indications  of  the  individual  case. 

One  maxim  though  must  always  be  observed :  ne  nimis !  As  advan- 
tageous as  is  a  definite  and  cautious  local  treatment,  just  so  bad  is  it  to 
carry  this  form  of  therapy  too  far.  My  experience  has  taught  me  that 
those  who  carry  local  treatment  too  far  make  just  as  great  a  mistake 
as  those  who  completely  discard  it. 

If  remnants  of  a  gonorrhoea  remain,  the  usual  measures,  particularly 
cauterization  of  the  colliculus  seminalis  with  a  few  drops  of  a  2% 
solution  of  silver  nitrate,  may  be  tried.  It  should  be  done  at  intervals, 
so  as  not  to  increase  the  already  existing  nervousness  of  the  patients; 
if  prostatitis  is  present,  the  gland  should  be  massaged,  the  rectal 
thermophore  used,  and  electrization  of  the  prostate  practised,  one  pole 
being  placed  in  the  rectum  and  the  other  over  the  symphysis.  The 
metal  sound,  the  psychrophore,  and  applications  of  cold  water  to  the 
genitals  may  be  used  in  conjunction  with  a  few  internal  remedies  and 
hygienic  and  dietetic  measures.  The  bromides  alone  or  in  combination 
with  ergot,  or  with  iron  and  arsenic,  according  to  the  indications  of 
the  individual  case,  are  useful  drugs.  Hygiene  consists  in  regulating 
the  diet  and  the  general  regimen  of  living  and  above  all  in  securing 
a  copious  daily  evacuation  of  the  bowrels.  Under  this  treatment  the 
pollutions  almost  always  become  fewer  and  the  spermatorrhoea  entirely 
disappears. 

Some  of  these  therapeutic  measures  are  identical  with  those  which  I 
use  in  sexual  neurasthenia,  as  abnormal  losses  of  semen  are  often  only 
a  symptom  of  neurasthenia. 

It  is  evident  that  the  employment  of  the  local  measures  just  mentioned 
will  have  to  be  more  restricted  in  the  case  of  patients  of  neuropathic 
taint.  They  are  only  permissible  for  the  purpose  of  inspiring  the 
patient  with  confidence  that  he  will  be  cured.  The  disease  being  one 
in  which  the  greatest  desideratum  is  an  alteration  of  the  patient's 
mental  condition,  treatment  naturally  must  be  psychical.  This  gives 
results  only  when  the  physician  possesses  great  authority  and  has 
the  complete  confidence  of  his  patient. 

The  first  object  of  suggestive  treatment  should  be  to  impress  the 


582  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

patient  with  the  idea  that  his  disease  is  not  so  severe  as  hebelieves,and 
that  he  will  soon  get  better  and  be  cured  within  a  conceivable  time. 

The  best  results  are  obtained  by  hygienic-dietetic  treatment  in  a 
sanitarium.  The  same  measures  employed  at  home  do  not  have  the 
effect  that  they  have  when  the  patient  is  removed  from  his  usual  sur- 
roundings and  vocation.  Therefore  it  is  best  for  well-to-do  patients 
to  go  to  a  suitable  sanitarium  and  take  a  systematic  course  of  treat- 
ment. Regulation  of  the  bowels;  light,  non-stimulating  food  eaten 
at  regular  intervals;  the  interdiction  of  alcoholic  beverages  and  the 
restriction  of  tobacco;  prescribed  exercises  together  with  physical  labor 
in  the  intervals  when  possible;  gymnastics,  massage,  galvanic  or  faradic 
electrization;  hydrotherapeutic  measures,  such  as  full  baths,  half 
baths  and  sitz-baths,  douches  at  first  luke  warm  and  then  gradually 
reduced  in  temperature,  together  with  friction; — these  are  the  remedies 
with  which  the  institution-physicians  obtain  such  surprising  results. 

Change  of  air,  a  sojourn  in  the  country,  sea  baths  and  traveling  also 
have  a  beneficial  effect  upon  the  mental  and  physical  condition.  Those 
who  are  not  able  to  go  to  a  health-resort  or  travel  should  be  treated 
according  to  the  same  principles  at  home.  As  to  medical  treatment 
I  recommend  the  various  bromine  salts,  ergotin  and  strychnine,  with 
or  without  the  addition  of  iron  and  arsenic,  according  to  indications. 

IMPOTENTIA  VIRILIS. 

By  impotentia  virilis  is  understood  a  condition  in  which  the  power  of 
having  normal  sexual  intercourse  is  entirely  lost  or  considerably  dimin- 
ished. 

This  disease  is  more  accurately  called  impotentia  cceundi  in  contra- 
distinction to  impotentia  generandi,  which  implies  a  defect  in  the  semen, 
or  in  other  words  in  its  impregnating  power.  Both  render  the  indi- 
vidual incapable  of  propagating  his  kind,  unless  artificial  methods  of 
fecundation  are  resorted  to  in  the  former  condition.  With  few  excep- 
tions, which  will  be  referred  to  later,  those  who  are  unable  to  copulate 
are  also  unable  to  procreate;  on  the  other  hand  inability  to  procreate 
does  not  imply  incapacity  to  copulate. 

There  are  many  men  whose  power  of  impregnation  is  lost,  but  yet 
who  are  able  to  have  intercourse  in  a  normal  manner;  and,  vice  versa, 
there  are  many  others  whose  testicles  produce  an  entirely  normal 
secretion,  and  who  therefore  are  not  sterile  in  the  strict  sense  of  the 
word,  although   their  inability  to   secure   intromission   of  the  penis 


ORGANIC    IMPOTENCE.  583 

renders  them  incompetent  to  procreate.  Those  exceptional  cases  in 
which  emission  takes  place  although  the  penis  is  only  partly  or  not  at 
all  rigid  are  to  be  excluded  from  this  class,  as  conception  may  occur  if 
the  seminal  fluid  gets  into  the  vagina. 

Impotentia  cceundi,  the  more  important  of  the  two  affections, 
will  be  considered  first.  Apart  from  the  existence  of  normal  genital 
organs,  the  indispensable  condition  for  the  performance  of  the  sexual 
act  is  a  good  erection,  so  it  naturally  follows  that  absence  or  insufficiency 
of  erection  constitutes  the  cause  of  impotence.  This  defect  may 
relate  to  the  time  during  which  the  penis  remains  rigid,  to  the  degree 
of  rigidity  which  it  attains,  or  to  faulty  direction  of  the  perfectly  rigid 
penis. 

According  to  the  cause  upon  which  impotence  depends  we  recognize : 

1.  Organic  impotence. 

2.  Psychical  impotence. 

3.  Nervous  impotence. 

4.  Paralytic  impotence. 

1.  ORGANIC  IMPOTENCE. 

In  this  form  the  inability  to  copulate  depends  upon  malformation 
or  defect  of  the  genital  organs  or  neighboring  structures.  Among  these 
are  absence  or  rudimentary  formation  of  the  penis  and  exstrophy  of  the 
bladder  with  very  short  penis.  Epispadias  and  hypospadias  do  not 
always  cause  impotence.  I  know  a  great  many  men  afflicted  with  one 
or  the  other  of  these  conditions  who  are  able  to  perform  the  sexual  act 
very  satisfactorily,  even  though  the  semen  is  not  ejected  into  the 
vagina,  but  escapes  above  or  underneath.  It  is  only  in  the  extreme 
grades  of  this  abnormality  that  coitus  is  impossible. 

When  the  penis  is  completely  or  mostly  retracted  into  the  scrotum 
in  consequence  of  scrotal  hernia,  hydrocele,  elephantiasis  or  tumors  of 
the  scrotum,  it  is  useless  as  far  as  the  sexual  function  is  concerned.  In 
reducible  hernias  a  truss,  and  in  the  other  abnormalities  proper  opera- 
tive procedures,  will  afford  relief. 

Mutilation  or  abnormal  size  of  the  penis  may  also  hinder  cohabita- 
tion. Elephantiasis  of  the  glans  or  body  of  the  penis,  tumors  of  the 
glans,  urethral  or  preputial  calculi  may  interfere  with  or  completely 
prevent  intromission. 

The  prognosis  of  these  cases  is  usually  favorable.     Sometimes  the 


584  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

abnormalities  can  be  removed  by  operation  without  destroying  the 
form  of  the  penis.  Even  when  it  is  necessary  to  cut  off  the  anterior 
portion  of  the  organ  enough  often  remains  for  the  patient  to  have 
connection. 

Impotence  may  be  caused  by  congenital  or  acquired  shortness  of  the 
fraenum,  so  that  it  bends  the  end  of  the  penis  downwards.  In  such 
cases  even  though  cohabitation  is  possible  it  is  usually  so  painful  that 
the  individual  is  compelled  to  abstain  from  it.  Cure  is  readily  obtained 
by  dividing  the  fraenum. 

It  has  also  been  stated  that  varix  of  the  dorsal  vein  of  the  penis  may 
prevent  connection. 

If  the  penis  is  deflected  to  one  side  or  upwards  or  downwards  when 
it  becomes  erect,  this  deformity  may  prevent  or  at  least  render  inter- 
course difficult.  The  trouble  depends  upon  the  degree  of  deviation, 
which  in  turn  is  due  to  circumscribed  infiltrations  or  indurations  of  the 
corpora  cavernosa  or  their  fibrous  sheath.  These  infiltrations  may  be 
multiple  or  single,  they  may  be  limited  to  one  corpus  cavernosum,  as  is 
generally  the  case,  or  they  may  surround  the  whole  penis.  They  may 
also  extend  into  the  corpus  spongiosum.  In  consistency  they  may  be 
soft  or  as  hard  as  cartilage. 

When  erection  occurs  deviation  of  the  penis  results,  as  the  spaces 
within  the  corpora  cavernosa  are  obliterated  at  the  site  of  the  infil- 
trations so  that  they  cannot  expand.  The  deviation  occurs  toward  the 
side  on  which  the  indurations  are  situated. 

The  etiology  of  this  affection,  which  occurs  most  frequently  in  middle 
life,  is  not  clear  in  all  cases.  The  gouty  diathesis,  injuries  during 
coitus,  violent  erections,  and  gonorrhoea  have  been  specified  as  causes. 

Verneuil  found  diabetes  mellitus  in  nine  out  of  ten  cases  and  therefore 
believes  that  there  is  a  causal  relation  between  the  two  affections. 
Tufher  and  Pousson  also  found  them  associated.  In  several  of  the  cases 
which  I  have  observed  gonorrhoea  and  injury  seemed  to  be  the  cause. 
I  have  not  seen  any  cases  in  which  the  other  supposed  causes  were 
operative.  The  tumors  found  in  diabetes  are  usually  in  the  corpora 
cavernosa,  while  the  callosities  resulting  from  long-standing  gonorrhoea 
are  usually  first  situated  in  the  corpus  spongiosum,  from  which  they 
may  occasionally  extend  to  the  corpora  cavernosa.  They  are  most 
common  in  the  bulb  and  resemble  urethral  stricture;  they  are  also 
often  found  in  the  pendulous  portion  of  the  urethra. 

Periurethral  abscesses  producing  obliteration  of  the  affected  parts 


PSYCHICAL    IMPOTENCE.  585 

may  have  the  same  effect.  Johnsohn  saw  distorsion  of  the  penis 
follow  an  abscess  in  the  right  corpus  cavernosum. 

When  of  considerable  extent  or  rightly  situated,  ossification  of  the 
septum  or  fibrous  sheath  of  the  corpora  cavernosa  may  have  a  similar 
effect.  They  are  much  less  common  than  the  previously  mentioned 
affections  (Velpeau,  Malgaigne). 

Gummata  of  the  corpora  cavernosa  may  also  cause  deviation  of 
the  penis  during  erection  (Ricord).  Differential  diagnosis  between 
these  growths  and  callosities  and  bony  growths  will  seldom  be  difficult. 

Gummata  offer  the  best  prognosis  of  all  these  affections;  regular 
antisyphilitic  treatment  or  potassium  iodide  alone,  together  with  local 
inunctions  of  mercurial  ointment,  will  generally  prove  efficacious. 

Curvature  of  the  penis  due  to  laceration  of  the  corpora  cavernosa, 
commonly  called  fracture  of  the  penis,  offers  no  chance  of  cure. 

Ossifications  in  the  septum,  the  so-called  horns  of  the  penis,  may 
occasionally  be  removed  by  operation. 

The  nodules  occurring  in  diabetes  offer  a  good  prognosis.  They 
are  no  doubt  caused  by  this  disease,  as  they  become  smaller  when  it 
responds  to  treatment. 

The  most  difficult  to  cure  are  those  due  to  gonorrhoea.  Boyer  and 
Gross  recommended  the  excision  of  such  indurations.  This  procedure 
is  good,  although  it  is  subject  to  restriction.  Before  resorting  to  opera- 
tion other  measures  should  be  tried,  among  which  I  recommend  the  use 
of  sounds  of  increasing  size.  If  there  is  a  stricture  it  should  be  dilated 
with  soft  bougies.  After  the  urethra  will  admit  a  16  F.,  metal  sounds 
may  be  employed  and  their  size  constantly  increased.  Local  appli- 
cations of  mercurial  ointment,  warm  sitz-baths,  and  potassium  iodide 
internally  may  be  employed  as  auxiliary  measures.  Under  this  treat- 
ment I  have  seen  many  infiltrations  become  smaller  and  the  curvature 
of  the  penis  thus  become  less.  It  is  only  when  this  procedure  is 
ineffectual  and  the  infiltrations  are  multiple  or  large  that  excision 
should  be  undertaken. 

2.     PSYCHICAL  IMPOTENCE. 

,  Psychical  impotence  is  the  most  important  of  all  the  forms  of  impo- 
tence and,  moreover,  is  one  of  the  most  interesting  subjects  in  medi- 
cine. Its  clinical  picture  presents  unusual  diversities.  The  impair- 
ment of  virility  varies  greatly,  being  less  at  certain  times  than  it  is  at 
others. 


586  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

Although  the  conception  of  potency  may  be  relative,  it  is  neverthe- 
less constant  insofar  as  it  implies  capability  to  have  connection  at 
certain  intervals  of  time.  It  cannot  be  positively  stated  just  how  many 
times  a  man  should  be  able  to  copulate  within  a  given  period  of  time. 
The  age  of  the  man,  his  disposition,  his  sympathy  for  the  female,  and 
many  other  things  exert  an  influence.  There  is,  however,  a  certain 
physiological  measure.  If  this  is  diminished  we  speak  of  impotence, 
although  we  call  it  partial  impotence  in  contradistinction  to  absolute, 
in  which  the  individual  is  no  longer  able  to  perform  the  sexual  act. 

As  regards  the  age  at  which  a  man  is  able  to  copulate  and  the  time 
of  life  at  which  this  power  ceases,  it  naturally  varies,  depending  upon 
many  different  circumstances.  The  time  at  which  it  becomes  extinct 
is  even  more  variable  than  the  period  at  which  it  begins.  Many  men 
retain  their  virility  until  an  advanced  age,  while  others  lose  it  com- 
paratively early,  or  at  least  find  that  their  power  is  becoming  impaired. 
Sometimes  this  senile  condition  follows  an  exhausting  disease,  at 
others  it  supervenes  as  the  result  of  physiologic  processes.  In  the 
latter  instance  the  transition  from  potency  to  impotency  is  gradual. 
A  diminution  of  sexual  power  is  noticed;  while  it  was  possible  for  him 
to  have  connection  every  day,  such  a  person  now  finds  that  intervals 
of  constantly  increasing  duration  must  elapse  between  the  acts;  or  a 
longer  time  may  be  required  for  the  consummation  of  coitus;  or, 
whereas  formerly  any  erotic  excitation  sufficed  to  produce  an  erection, 
unusual  and  complicated  means  are  now  required. 

It  is  also  a  reduction  of  potency  when  a  man  is  able  to  cohabit  only 
with  certain  women.  This  form  of  impotence,  which  comes  under 
the  heading  of  psychical,  is  called  relative.  It  usually  affects  married 
men  who  cannot  have  intercourse  with  their  wife,  although  they  are 
potent  with  other  women. 

Just  as  virility  varies  in  different  men,  so  likewise  does  it  vary  in  the 
same  individual  according  to  external  conditions  and  physical  and 
mental  disposition;  it  is  to  the  latter  that  we  will  now  particularly 
direct  our  attention. 

It  has  already  been  stated  that  the  prerequisite  of  potency  is  an 
erection,  which  is  under  the  control  of  the  brain;  therefore  the  mind 
exerts  a  notable  influence  upon  the  sexual  functions.  Impotence  due 
to  mental  alterations  is  the  most  interesting  as  well  as  the  most  frequent 
and  readily  curable  form.  Only  those  cases  in  which  mental  impression 
is  the  exclusive  cause  can  be  placed  in  this  category. 


PSYCHICAL    IMPOTENCE.  587 

I  cannot  agree  with  those  authors  who  consider  frequent  attacks  of 
gonorrhoea,  prostatic  disease  and  inflammation  of  the  bladder  or 
testicles  to  be  causes.  These  troubles  are  responsible  for  psychical 
impotence  only  as  far  as  they  produce  mental  alterations.  As  long  as 
they  do  not  give  rise  to  such  changes  they  do  not  influence  sexual  power, 
a  fact  which  is  attested  by  thousands  of  cases  of  gonorrhoea.  They  do 
occasionally  give  rise  to  mental  impressions  which  disturb  the  sexual 
capacity,  but  this  is  quite  another  matter. 

Upon  investigation  of  the  etiological  factors  of  psychical  impotence 
it  is  found  that  they  are  many  and  diverse. 

Persons  who  have  led  a  most  moderate  sexual  life  or  who  may  even 
have  lived  continently  are  sometimes  affected,  and,  conversely,  those  who 
have  given  themselves  over  to  the  wildest  excesses,  who  have  indulged 
excessively  in  natural  intercourse  from  their  earliest  youth  and  thus 
overtaxed  their  power,  may  also  be  subject  to  it.  There  are  also  cases 
in  which  the  quality  of  coitus  does,  not  correspond  to  physiological  laws, 
in  which  unnatural  situations  and  subtle  means  on  the  part  of  the 
female  are  required  for  the  production  of  sexual  excitement.  Further- 
more persons  who  have  been  or  still  are  addicted  to  masturbation  are 
sometimes  affected,  and,  indeed,  they  constitute  the  largest  number  of 
this  class.  Finally  fear,  superstition,  hypochondria,  or  even  a  slight 
mental  impression  may  render  a  person  incapable  of  performing  the 
sexual  act. 

It  is  exceedingly  rare  for  persons  who  have  practised  sexual  inter- 
course very  moderately  or  not  at  all  to  suffer  from  psychical  impotence ; 
they  constitute  the  largest  contingent  of  those  who  are  afflicted  with 
nervous  irritative  impotence,  which  will  presently  be  described.  Such 
cases,  however,  do  occur  in  the  former  class  and  depend  upon  absence 
of  the  sexual  impulse.  The  sexual  impulse  leads  to  sensual  excitation, 
which  in  turn  leads  to  the  performance  of  the  sexual  act.  Therefore, 
if  this  impulse  is  absent,  the  desire  and  possibility  of  intercourse  is 
wanting. 

Absence  of  the  sexual  impulse  may  be  congenital  or  acquired.  The 
former  is  certainly  very  rare,  although  there  are  perfectly  healthy 
persons  who  have  never  experienced  sexual  desire. 

Such  sexual  anaesthesia  is  of  cerebral  origin.  It  is  not  dependent 
upon  absence  or  defect  of  the  external  organs  of  generation  or  the  spinal 
mechanism,  for  Ultzmann  and  myself  have  observed  cases  of  congenital 
aspermatism  in  which  virility  was  intact.     Only  those  cases  in  which 


588  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

sexual  life  is  wanting,  despite  normally  developed  and  functionally 
active  organs  of  generation,  come  under  this  category.  According  to 
Krafft-Ebing  this  form  generally  occurs  in  persons  who  are  affected 
with  other  functional  cerebral  disturbances,  or  who  show,  signs  of 
mental  and  perhaps  also  physical  degeneration. 

Closely  related  to  these  cases  of  defective  sexual  impulse  are  the  so- 
called  naturae  frigidce,  which  are  encountered  more  frequently  in  the 
female  than  in  the  male  sex.  Women  thus  constituted  have  only 
slight  inclination  for  connection,  derive  no  pleasure  from  it,  and  submit 
to  it  only  from  a  sense  of  duty. 

In  regard  to  acquired  absence  of  the  sexual  impulse,  mental  overwork 
or  diversion  is  most  to  blame.  When  the  mind  is  absorbed  in  thought 
sensual  excitation  is  not  experienced.  In  most  of  these  cases  the  im- 
potence is  only  temporary;  as  soon  as  the  cause  is  removed  the  effect 
disappears.  Cases  have  been  reported,  though,  in  which  the  mind 
was  so  engrossed  in  other  subjects  that  the  sexual  impulse  dwindled 
away  and  failed  to  develop  again  after  the  excessive  activity  had  ceased. 
It  is  said  that  Sir  Isaac  Newton  never  had  sexual  intercourse,  and  it 
may  well  be  believed  that  he,  who  was  occupied  with  problems  requir- 
ing the  most  assiduous  and  profound  thought,  never  felt  the  sexual 
impulse. 

It  is  different  in  those  cases  in  which  the  first  cause  of  an  unsuccessful 
coitus  was  a  mental  impression,  the  recollection  of  which  occasioned 
still  further  failures  upon  subsequent  attempts. 

An  interesting  explanation  of  the  manner  in  which  distrust  or  fear 
influences  potency  is  afforded  by  Goltz's  theory  of  inhibitor}7  centers 
in  the  brain.  It  will  be  remembered  that  Goltz  ascribes  an  inhibitory 
power  to  the  brain  by  means  of  which  the  center  of  erection  in  the 
spinal  cord  is  controlled.  Although  the  latter  may  endeavor  to  send 
out  impulses  for  the  production  of  an  erection,  it  is  prevented  from  so 
doing  by  the  irritated  inhibitory  center.  The  two  centers  are  in  con- 
flict; the  inhibitory  center  in  the  brain  is  the  stronger  and  conquers 
the  center  of  erection  in  the  cord. 

It  is  true  that  no  proof  of  the  correctness  of  this  theory  canbe  adduced, 
but  I  place  some  value  upon  it  as  it  explains  how  it  is  possible  for 
anxiety  to  prevent  the  occurrence  of  erection;  I  believe  that  a  large 
number  of  cases  of  psychical  impotence  are  attributable  to  this  cause, 
which  not  only  lends  weight  to  the  theory,  but  also  determines  the 
method  of  treatment.    As  we  shall  see  later,  in  the  majority  of  cases 


PSYCHICAL  IMPOTENCE.  589 

it  is  not  weakness  of  the  genitalia  or  nervous  system  resulting  from 
excesses  or  masturbation  which  leads  to  impotence,  but  rather  lack  of 
self-confidence  and  fear  that  these  digressions  may  have  inflicted  harm. 
The  stronger  this  fear  the  more  remote  the  cure. 

The  frequency  with  which  cure  is  obtained,  however,  confirms  this 
view.  As  soon  as  the  patients'  anxiety  is  removed,  a  thing  which  cannot 
always  be  easily  accomplished,  they  regain  their  virility.  In  order  for 
the  patient  to  be  freed  from  his  fear  it  is  necessary  first  of  all  for  him 
to  trust  his  physician  and  hope  that  he  will  be  benefited  by  the  treat- 
ment prescribed. 

For  this  reason  I  lay  great  stress  upon  prescribing  a  detailed  plan  of 
treatment  for  these  patients. 

I  either  send  them  to  a  watering  place  and  have  them  take  a 
thorough  course  of  treatment  under  the  supervision  of  a  physician,  or 
treat  them  at  home  by  means  of  general  electrization,  local  faradization 
of  the  genitals,  which  produces  erections,  artificial  carbonic  acid  baths, 
sounds  of  increasing  size,  cold  rubs,  cold  baths,  and  the  internal 
administration  of  placebos.  It  is  very  advantageous  to  employ  several 
of  these  measures  at  the  same  time ;  the  less  the  patient's  time  is  occu- 
pied the  greater  the  number  which  should  be  used.  The  patient  will 
then  believe  that  a  great  deal  is  being  done  for  him  and  gain  hope  that 
the  treatment  will  be  beneficial. 

It  is  most  essential  for  the  patient  to  abstain  from  coitus  for  a  long 
time.  He  must  not  be  allowed  to  attempt  it  every  week  for  the  purpose 
of  testing  his  power,  for  a  failure  will  greatly  retard  his  recovery.  I 
have  my  patients  abstain  for  months  at  a  time;  they  then  get  the  idea 
that  this  long  rest  has  so  fortified  their  genital  organs  that  they  are 
again  fully  able  to  have  connection. 

In  like  manner  fear  of  failure  is  responsible  for  many  cases  of 
psychical  impotence  following  excesses  in  natural  coitus  or  mastur- 
bation. 

There  is  a  general  impression  among  the  laity  that  excessive  venery 
leads  to  early  loss  of  sexual  power,  and  it  is  certainly  well  that  they  think 
so,  as  otherwise  excesses  would  be  even  more  common  than  they  are. 
As  it  is,  many  are  restrained  from  the  dissolute  practices  to  which  their 
nature  impels  them  through  fear  of  the  consequences. 

Others,  however,  are  reckless  or  their  desires  conquer  their  discretion. 
Then  it  comes  to  pass  that  coitus  goes  amiss,  be  it  that  erection  does 
not  occur  when  it  is  needed  or  subsides  too  soon,  be  it  that  an  unusual 


590    FUNCTIONAL  DISTURBANCES  OF  THE  SEXUAL  ORGANS. 

length  of  time  and  unusual  effort  are  required  for  the  consummation 
of  the  act;  in  short,  it  is  noticed  that  coitus  is  not  performed  as  it 
formerly  was. 

This  need  not  result  from  excesses,  there  being  many  other  causes 
which  explain  its  occurrence.  The  affected  person  may  be  physically 
or  mentally  exhausted  or  his  thoughts  diverted  to  other  subjects. 
He  may  have  been  under  the  influence  of  drink  or  his  feeling  toward 
his  female  companion  have  been  very  slight;  finally  uncleanliness, 
disagreeable  odor,  or  vulgar  conduct  may  have  produced  a  feeling  of 
disgust  or  aversion.  Any  one  of  these  suffices  to  explain  why  con- 
nection is  not  as  satisfactory  as  it  formerly  was. 

The  patients,  however,  naturally  attribute  it  to  their  sexual  excesses 
and  look  upon  it  as  a  form  of  punishment.  When  we  come  to  consider 
atonic  impotence  we  shall  see  that  they  are  often  right,  although  it  is 
often  only  one  of  these  accidental  causes,  together  with  transitory  weak- 
ness, which  produces  the  failure.  If  this  once  comes  to  pass,  fear 
ensues  that  it  may  happen  again,  and  it  is  this  thought  of  failure  more 
than  anything  else  which  prevents  the  occurrence  of  erection. 

Of  minor  importance  are  those  temporary  forms  of  impotence  which 
sometimes  immediately  follow  excesses.  If  a  man  has  connection 
several  times  a  night  for  several  nights  in  succession,  it  is  only  natural 
that  he  should  fail  when  he  tries  again  after  a  short  lapse  of  time,  as 
sexual  energy  is  in  relation  with  the  amount  of  seminal  fluid  and  nervous 
energy  which  is  stored  up.  If  the  former  is  spent  and  the  latter  ex- 
hausted, coitus  naturally  cannot  take  place.  These  conditions  are  so 
well  understood  by  the  laity  that  they  do  not  give  rise  to  the  fear 
previously  mentioned.  It  is  known  that  proper  rest  will  put  things 
in  order  again. 

In  many  cases,  too,  marital  conditions  are  the  cause  of  relative  im- 
potence. Thus  a  married  man  may  have  no  trouble  in  having  connec- 
tion with  other  women  although  he  is  not  able  to  with  his  wife.  Such 
cases  have  been  observed  in  men,  who  in  course  of  time  have  taken  an 
aversion  to  their  wife,  in  those  whose  wife  aged  early,  and  in  those  who 
found  relations  with  other  women  so  congenial  that  they  no  longer 
derived  pleasure  from  intercourse  with  the  woman  to  whom  they  are 
wedded.  Under  these  circumstances  it  is  naturally  difficult  for  the 
physician  to  effect  any  change. 

We  now  come  to  a  group  of  cases  of  psychical  impotence  which  are 
caused  by  an  aberration  of  mind  relative  to  sexual  matters,  namely, 


PSYCHICAL    IMPOTENCE. 


591 


perverse  sexual  feeling.  These  cases  have  received  more  attention 
from  writers  on  medical  jurisprudence,  but  they  are  nevertheless  of 
particular  interest  and  great  importance  from  our  point  of  view.  The 
normal  man  feels  the  sexual  impulse  under  circumstances  which  are 
too  well-known  to  require  detailed  description  here.  The  sight  of 
nude  or  partly  disrobed  women,  contact  or  lewd  conversation  with  them, 
obscene  pictures  and  the  like  awaken  ideas  which  produce  sexual 
excitement,  as  the  expression  of  which  an  erection  of  the  penis  occurs. 

It  is  different  with  persons  having  perverse  sexual  impulses.  That 
which  arouses  the  physiological  sexual  feeling  in  normal  men  has  no 
effect  upon  them;  their  sexual  nature  is  excited  by  circumstances 
which  have  no  influence  whatever  upon  normal  men.  For  example, 
the  sight  of  women's  hose  or  shoes  makes  no  impression  upon  a  normal 
man;  I  have  a  patient,  however,  who  experiences  sexual  excitement 
only  when  he  looks  at  the  former  article  of  apparel. 

It  is  easily  explainable  how  such  perverse  feelings  may  result  in 
impotence.  Persons  thus  afflicted  cannot  get  an  erection  when  they 
try  to  have  connection,  because  those  things  which  excite  them  sexually 
are  absent.  The  libido  sexualis,  however,  is  strong,  indeed  it  is  often 
too  well  developed. 

A  large  number  of  such  persons  are  masturbators,  that  is,  contem- 
plative masturbators  [Gedanken-Onanisten]  in  contradistinction  to 
those  who  produce  orgasm  and  ejaculation  by  frictioning  the  penis 
without  further  voluptuous  fancies;  they  picture  unto  themselves  the 
most  marvelous  relations  with  women.  This  arouses  their  lust  and 
erection  and  ejaculation  follow.  When  they  come  in  contact  with 
women  and  try  to  have  connection,  they  remain  unmoved;  they  fail 
to  find  in  reality  that  which  their  fantasy  had  depicted;  no  erection 
occurs,  they  are  impotent. 

Perverse  sexual  impulse,  then,  may  express  itself  as  a  mere  imagina- 
tive proceeding,  as  in  the  case  of  the  contemplative  masturbators, 
or  in  the  actual  performance  of  an  unnatural  sexual  act  with  other 
persons.  These  persons  may  be  of  either  sex;  it  matters  not  so  far  as 
the  result  is  concerned. 

The  perversity  of  the  conception  often  relates  to  secret  things  which 
are  usually  concealed  from  the  eyes  of  men,  although  it  may  concern 
matters  which  bear  absolutely  no  relation  to  anything  ordinarily  capable 
of  arousing  sexual  excitement,  or  relate  to  objects  which  are  seen  every- 
where  and   have   nothing   whatsoever  indecent   about   them.     Thus 


592  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

Charcot  and  Magnan  report  a  case  in  which  the  thought  of  a  night-cap 
aroused  sexual  desire. 

It  is  interesting  to  note  that  in  those  cases  in  which  an  inadequate 
stimulus  evokes  sexual  desire,  although  adequate  physiological  stimuli 
remain  without  effect,  the  inadequate  stimulus  may  be  used  to  render 
coitus  possible.  This  supplies  the  basis  upon  which  treatment  must 
be  founded. 

Thus  there  are  persons  who  satisfy  their  sexual  cravings  by  mere 
contemplation  or  conception  of  inanimate  objects  at  onetime,  and  by 
perverse  acts  upon  their  own  person  at  another.  To  this  class  also 
belong  those  who  seek  to  appease  their  lust  by  perverse  practices  upon 
persons  of  their  own  or  the  opposite  sex,  or  upon  animals. 

The  perverse  acts  which  are  practised  with  persons  of  the  same  sex 
merely  represent  an  increase  in  the  perverse  ideas  relating  to  persons 
of  the  opposite  sex  upon  which  the  mind  of  the  afflicted  individual  is 
concentrated.  Just  as  in  some  cases  sexual  enjoyment  is  derived  from 
the  sight  or  conception  of  women's  shoes  or  similar  objects,  in  others 
it  is  obtained  by  acts  of  the  most  disgusting,  horrible  and  criminal 
nature.  Among  these  are  the  terrible  deeds  committed  for  the  purpose 
of  satisfying  sexual  passion,  the  acts  of  the  sadists. 

As  difficult  as  it  is  to  understand  this  combination  of  sensuality  and 
cruelty  there  are  nevertheless  certain  weak  analogies  to  it  in  physio- 
logical life. 

Thus  there  is  some  relation  between  these  acts  and  the  well-known 
fact  that  very  sensuous  women  not  uncommonly  bite  the  man  with 
whom  they  are  having  connection  when  the  climax  of  coitus  is  reached. 

If  the  conception  productive  of  sensual  pleasure  attain  a  higher 
degree  and  assume  a  murderous  or  criminal  trend,  deeds  of  violence 
result. 

The  adequate  sexual  stimulus  in  the  case  of  such  perverts  is  the 
conception  of  the  pain  suffered  by  their  victim.  From  this  conception 
is  generated  the  impulse  to  commit  such  deeds  for  the  gratification  of 
lustful  desire. 

The  principal  form  of  sexual  perversion,  however,  is  love  for  those 
of  the  same  sex.  Here  we  encroach  upon  a  domain  to  which  the 
criminal  judge  lays  claim;  nevertheless  the  treatment  of  human  weak- 
ness which  devolves  upon  the  physician  comprises  psychical  as'well  as 
physical  conditions,  and  as  paederasty  is  a  form  of  mental  aberration 
it  should  for  this  reason  receive  our  attention. 


PSYCHICAL    IMPOTENCE.  593 

Love  for  one's  own  sex,  or  paederasty,  may  be  congenital  or  acquired. 

In  the  first  case  the  sexual  disturbances  depend  upon  a  psychopathic 
or  neuropathic  constitution,  that  is,  they  occur  in  persons  of  bad 
heredity.  These  persons  experience  no  sexual  excitation  through 
physiological  stimuli,  as  for  example,  the  sight  of  a  naked  woman, 
although  the  nude  male  figure  is  an  adequate  stimulus.  If  they  try 
to  have  connection  with  a  woman  they  fail,  and  unless  they  are  morally 
degenerate,  so  that  they  cannot  realize  the  abnormality  of  their  condi- 
tion, the  failure  increases  their  despondency  and  mental  suffering. 

Masturbation  must  have  an  especially  unfavorable  influence  upon  the 
sexual  life  of  a  person  of  such  a  bad  heredity.  It  acts  as  a  predisposing 
cause  for  the  development  of  paederasty.  When  such  an  individual 
who  was  addicted  to  masturbation  in  his  early  years  attains  a  mature 
age,  he  does  not  possess,  writes  Krafft-Ebing,  "  the  aesthetic,  ideal,  pure 
and  natural  feeling  which  attracts  him  to  the  other  sex.  Thus  the 
ardor  of  sensual  feeling  is  extinguished  and  affection  for  the  opposite 
sex  very  much  reduced.  This  defect  has  an  unfavorable  influence 
upon  the  moral  and  mental  condition,  upon  the  character,  disposition, 
impulses  and  emotions  of  young  masturbators  of  either  sex,  and  under 
certain  circumstances  causes  the  desire  for  the  other  sex  to  die  out,  so 
that  masturbation  is  preferred  to  the  natural  method  of  appeasing 
sexual  desire." 

In  acquired  paederasty  it  is  generally  misguidance  on  the  part  of 
others  and  the  impossibility  of  satisfying  the  sexual  impulse  which 
makes  otherwise  normal  men  paederasts.  Therefore  it  is  no  wonder 
that  the  vice  is  particularly  common  in  closed  and  guarded  institutions, 
such  as  boarding-schools,  monasteries  and  prisons,  and  also  on  board 
ships.  It  more  rarely  happens  that  married  persons  practise  it  in  order 
to  avoid  increase  in  the  family.  It  most  commonly  originates  in 
educational  institutions  where  one  boy  with  perverse  sexual  feelings 
seduces  other  pupils.  Under  the  influence  of  example  and  the  desire 
which  is  uppermost  in  the  mind  the  children  conquer  their  disgust, 
inflame  their  imagination  with  obscene  pictures,  and  indulge  in  peder- 
asty. 

Homosexual  propensities  are  also  often  observed  in  old  people, 
mostly  old  rakes  whose  senses  have  become  dulled  to  natural  stimuli. 
They  find  no  pleasure  in  normal  sexual  intercourse,  sink  morally  lower 
and  lower,  and  finally  abandon  themselves  to  the  loathsome  vice  of 
paederasty. 
40 


594  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

In  this  category  also  belong  the  so-called  Sodomites,  persons  who 
practise  lustful  acts  with  animals.  Sodomy  was  an  element  of  re- 
ligious cults  among  many  ancient  peoples,  notably  among  the  Egyp- 
tians. There  are .  different  causes  which  lead  men  to  rape  animals. 
It  is  generally  weak-minded  cretins  or  insane  persons  who  commit 
these  acts  during  their  periodical  outbursts  of  sexual  passion.  It  is 
only  exceptionally  that  persons  of  apparently  sound  mind,  who  have 
not  the  opportunity  of  satisfying  their  lust  in  the  natural  manner,  will 
abuse  animals  if  they  get  the  chance;  it  is  an  exceedingly  rare  occur- 
rence for  a  man  or  woman  to  conceive  a  passion  for  an  animal.  In 
such  cases  the  persons  are  usually  neuropaths  whose  sexual  inclinations 
are  toward  animals  and  whose  passion  is  aroused  by  the  revolting  deeds 
which  they  commit  upon  them. 

3.  NERVOUS  IMPOTENCE. 

This  form  of  impotence,  which  is  also  known  as  impotence  due  to 
irritable  weakness,  and  is  often  associated  with  sexual  neurasthenia, 
resembles  the  two  principal  forms  already  described,  in  that  it  is  not 
caused  by  organic  lesions  of  the  central  nervous  system.  The  genital 
organs  and  the  nervous  mechanism  controlling  them  are  anatomically 
sound,  but  functionally  deficient.  All  cases  in  which  anatomical 
lesions  are  demonstrable  or  probably  present  do  not  belong  to  this 
group,  but  come  under  the  last  division,  namely,  paralytic  impotence. 

In  the  present  class  of  cases  there  is  a  functional  defect  the  nature  of 
which  is  not  always  easily  determinable.  To  draw  a  comparison  for 
the  purpose  of  illustration  let  one  imagine  a  lighting  apparatus  con- 
sisting of  an  electric  battery  connected  by  conducting  coils  to  a  platinum 
wire.  The  power  of  the  battery,  however,  is  so  great  that  when  the 
current  is  turned  on  the  platinum  wire  soon  glows  through,  so  that  a 
lasting  light  is  not  given  off.  Here  all  is  sound,  battery  as  well  as  wire, 
and  yet  the  apparatus  does  not  work  as  it  should.  If  the  dispropor- 
tion between  the  two  parts  is  removed,  and  they  are  adjusted  one  to 
the  other,  the  whole  will  then  act  properly. 

Similar  conditions  may  be  assumed  in  impotence  due  to  irritable 
weakness.  In  this  condition  ejaculation  takes  place  at  the  moment 
intromission  of  the  penis  occurs  or  even  before  it  can  be  inserted  into 
the  vagina.  At  the  moment  when  coitus  should  begin  the  penis  becomes 
flaccid;  men  thus  affected  must  naturally  be  considered  impotent. 


NERVOUS    IMPOTENCE.  595 

Just  as  the  battery  in  the  lighting  apparatus  was  too  strong,  so  here 
are  the  nerves  too  strong;  they  occasion  orgasm  and  ejaculation  too 
soon,  with  the  result  that  coitus  cannot  be  continued. 

I  have  chosen  this  comparison  because  in  irritative  nervous  impotence 
there  is  an  excessive  nervous  activity.  According  to  my  experience 
those  who  suffer  from  this  complaint  are  mostly  young  men  who  have 
indulged  in  sexual  intercourse  very  rarely  or  not  at  all. 

The  report  of  a  case  may  serve  as  an  illustration.  A  young  man, 
twenty-three  years  of  age  and  of  a  well-to-do  family  complained  that 
it  was  impossible  for  him  to  have  connection,  as  ejaculation  always 
took  place  before  he  could  secure  intromission  of  the  penis.  He  could 
obtain  a  good  erection,  but  it  would  subside  too  soon.  He  considered 
his  condition  humiliating  and  unendurable,  and  feared  that  it  would 
keep  him  from  marrying. 

This  young  man  was  the  only  son  of  his  parents,  who  had  watched 
him  with  unremitting  care,  so  that  it  had  been  impossible  for  him  to 
indulge  in  sexual  intercourse.  When  he  became  somewhat  freer  he 
made  the  attempt  but  failed,  and  the  fiasco  was  repeated  upon  each 
subsequent  trial.  His  statement  that  he  had  never  masturbated  was 
accepted,  as  he  was  upright  and  truthful.  He  had  had  an  emission 
once  or  twice  a  month. 

The  present  trouble  had  existed  for  three  years  without  changing 
much,  although  he  had  become  able  to  secure  intromission,  whereupon 
ejaculation  occurred  at  once.     The  case  was  cured  by  marriage. 

The  condition  here  was  evidently  due  to  hypersensitiveness.  In 
consequence  of  the  long  repression  of  his  sensual  desires  the  otherwise 
perfectly  healthy  man  became  so  excited  that  the  orgasm  occurred 
sooner  than  in  other  men.  The  excessive  irritability  became  tempered 
in  wedlock,  an  occurrence  which  I  have  had  the  opportunity  of 
observing  in  other  cases. 

Two  other  cases  may  be  cited  as  representing  certain  types.  One 
is  that  of  a  young  lawyer,  and  is  worthy  of  notice  on  account  of  its 
termination.  The  patient,  a  strong,  handsome  man,  was  not  watched 
so  closely  as  the  one  previously  mentioned,  so  that  he  early  had  the 
opportunity  of  entering  into  sexual  relations. 

During  his  student  days  he  developed,  from  what  cause  is  unknown, 
a  general  nervous  condition  which  expressed  itself  in  the  form  Of  great 
agitation,  restlessness,  inability  to  work  and  sleeplessness.  In  addition 
he  experienced  a  tickling  sensation  in  the  urethra,  which  gave  rise  to 


596  FUNCTIONAL    DISTURBANCES    OF   THE    SEXUAL    ORGANS. 

frequent  erections  and  caused  precipitate  ejaculation  whenever  coitus 
was  attempted. 

The  patient  was  not  of  bad  heredity  and  had  masturbated  very  little 
during  his  youth;  the  genital  organs  were  well  developed  and  the 
urethra  as  revealed  by  the  endoscope  was  entirely  normal;  its  sensibility 
was  diminished  rather  than  increased. 

His  illness,  particularly  the  sexual  disturbance,  caused  him  to  become 
hypochondriacal.  I  sent  him  to  a  hydrotherapeutic  institute  where  he 
took  a  mild  course  of  treatment.  Upon  his  return  he  did  not  feel  much 
better.  He  was  afraid  to  marry  because  he  thought  he  might  not  be 
able  to  fulfill  his  marital  obligations.  I  endeavored  to  quiet  his 
fears  and  convince  him  that  such  would  not  be  the  case ;  indeed,  I  even 
recommended  marriage  as  a  cure. 

He  did  as  I  advised  him.  I  had  forewarned  him  that  in  the  beginning 
of  his  married  life  matters  would  go  even  worse  than  with  members  of 
the  demi-monde,  but  that  he  should  not  be  disturbed  by  this.  I  tried 
to  make  him  understand  that  his  trouble  was  one  which  would  diminish 
day  by  day.  Three  months  after  his  wedding  I  saw  him  again.  He 
stated  that  matters  went  exactly  as  I  had  predicted.  At  first  ejaculation 
took  place  before  intromission,  then  he  gradually  became  able  to  secure 
intromission  before  the  semen  was  discharged,  and  at  length  got  so 
that  he  could  have  normal  coitus. 

If  we  now  consider  a  third  case  we  shall  have  had  an  example  of  all 
the  forms  of  impotence  belonging  to  this  class.  It  is  that  of  a  school- 
master who  had  masturbated  considerably  in  his  youth.  Neurasthenic 
symptoms  were  not  long  in  manifesting  themselves.  The  patient  was 
restless,  unsettled  in  mind,  and  suffered  from  insomnia,  a  sense  of 
pressure  in  the  head,  and  irritation  in  the  posterior  urethra  and  at  the 
external  meatus.  Emissions  occurred  three  or  four  times  a  week, 
and  were  followed  by  great  weakness,  depression  and  ill-humor.  Now 
and  then  a  spontaneous  discharge  of  prostatic  fluid  took  place.  Coitus 
was  impossible  because  ejaculation  occurred  before  the  patient  could 
secure  intromission  of  the  penis. 

Upon  examination  I  found  the  patient  highly  nervous,  the  genitals 
well  developed,  the  urethral  orifice  reddened,  the  urethra  of  normal 
caliber,  but  excessively  sensitive  in  the  posterior  portion.  In  this  case, 
therefore,  there  was  sexual  neurasthenia,  prostatorrhcea,  and  irritative 
nervous  impotence. 

I  placed  the  patient  upon  treatment  and  made  a  favorable  prognosis. 


NERVOUS    IMPOTENCE.  597 

I  sent  him  to  a  hydrotherapeutic  institute  where  he  received  tepid  baths 
followed  by  cold  douches,  together  with  general  faradization  and  a 
partial  rest-cure.  When  he  returned  home  I  undertook  to  reduce  the 
hyperesthesia  of  the  urethra.  For  this  purpose  I  applied  a  five  per  cent 
solution  of  silver  nitrate  to  the  entire  posterior  urethra  once  a  week. 
On  the  last  three  days  of  the  week  large  sounds  of  ascending  sizes 
were  passed.  I  used  cocaine  at  first,  but  was  soon  able  to  dispense  with 
it.  The  meatus  was  large  enough  readily  to  admit  a  number  30  French. 
Potassium  bromide  and  ergotin  were  administered  internally. 

Under  this  treatment  the  patient,  who  had  not  attempted  to  have 
intercourse  for  three  months,  improved  considerably,  the  pollutions 
becoming  less  frequent  and  the  annoying  tickling  in  the  urethra  sub- 
siding. Thereupon  I  advised  marriage.  The  patient,  although  some- 
what doubtful,  followed  my  advice  and  married,  with  the  result  that  he 
was  completely  cured  of  his  nervousness  and  impotence. 

These  three  cases  represent  the  forms  of  irritative  nervous  impotence 
commonly  met  with  in  practice. 

In  the  first  case  it  was  complete  abstinence  which  led  to  a  condition 
of  excessive  irritability,  in  the  other  two  general  neurasthenia  existed, 
the  cause  being  unknown  in  one  instance  and  attributable  to  mastur- 
bation in  the  other. 

I  would  not  venture  to  decide  whether  the  urethral  irritation  present 
in  the  last  case  was  a  manifestation  of  the  general  neurasthenia  or 
whether  it  was  the  cause  of  the  latter.  This  is  the  question  which 
invariably  presents  itself  in  these  cases.  Many  incline  to  the  opinion 
that  the  redness  and  swelling  of  the  colliculus  seminalis  caused  by  mas- 
turbation produces  nervousness  in  the  form  of  priapism  and  precipitate 
ejaculation. 

This  theory,  which  presupposes  the  existence  of  a  peripheral  neuritis 
affecting  the  sexual  nerves  and  emanating  from  the  colliculus  seminalis, 
has  something  attractive  about  it,  inasmuch  as  it  affords  a  firm  working- 
basis  of  treatment,  but  as  a  matter  of  fact  it  may  not  be  correct ;  anatom- 
ical proof  has  not  been  adduced  in  every  case.  It  is,  however,  certain 
that  local  treatment  of  the  inflamed  parts  generally  relieves  not  only  the 
local  trouble,  but  also  the  general  nervous  condition. 

In  every  case  of  this  form  of  urethral  inflammation,  whether  it  be  the 
cause  or  concomitant  of  impotence,  it  is  the  duty  of  the  surgeon  to 
endeavor  to  reduce  the  hyperesthesia. 

Indeed,  blunting  of  this  urethral  sensibility  is  indicated  in  those 


598  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

cases  in  which  the  erection  is  perfect,  intromission  successful,  and  coitus 
therefore  possible,  but  the  time  required  for  ejaculation  too  short.  In 
certain  men  of  vivacious  temperament  precipitate  ejaculation  is  normal, 
and  it  also  sometimes  occurs  in  men  of  less  brisk  disposition  who  have 
not  had  intercourse  for  a  long  time.  If  this  condition  is  transitory  it  is 
not  important,  but  if  it  is  of  long  duration  it  requires  consideration  by 
reason  of  its  action  upon  the  procreative  power. 

According  to  the  views  now  accepted  the  manner  in  which  the  semen 
reaches  the  generative  passages  is  of  some  consequence.  It  is  believed 
that  certain  reflex  movements  of  the  cervix  and  os  uteri  favoring  recep- 
tion of  the  semen  take  place  during  coitus.  If  coitus  be  inopportunely 
terminated  by  early  ejaculation,  the  female  fails  to  reach  that  degree  of 
excitement  requisite  for  the  production  of  these  reflex  movements. 
Therefore  precipitate  ejaculation  bordering  upon  impotence  demands 
treatment  because  of  its  influence  upon  conception. 

4.  PARALYTIC  IMPOTENCE. 

This,  the  fourth  form  of  impotence,  differs  materially  from  the 
others. 

The  first  three  forms  are  alike  in  that  the  sexual  apparatus  so  func- 
tionates that  coitus  would  be  possible  were  it  not  for  certain  hindering 
circumstances  which  are  present.  In  the  first  form  it  is  absence  or 
malformation  of  the  genital  organs  or  disease  of  neighboring  parts 
which  renders  the  performance  of  the  sexual  act  mechanically  impos- 
sible. In  psychical  impotence  it  was  seen  that  sexual  power  is  often 
strong,  but  that  it  manifests  itself  at  the  wrong  time  or  in  the  wrong 
way.  In  the  third  class  also  the  sexual  organs  were  functionally 
active,  only  their  activity  was  too  great.  It  was  hypererethism  which 
prevented  the  consummation  of  coitus. 

In  paralytic  impotence  all  is  different.  In  consequence  of  struc- 
tural lesions  in  the  muscular  and  particularly  the  nervous  apparatus 
which  are  in  relation  with  the  genital  organs,  the  patients  are  deprived 
of  the  first  prerequisite  for  the  performance  of  coitus,  namely,  erec- 
tion. This  is  not  the  case  in  any  of  the  first  three  forms;  erection 
occurred,  but  could  not  properly  be  made  use  of. 

The  genitals  of  such  patients  sometimes  show  no  greater  changes 
than  are  observed  in  the  other  forms.  Occasionally  they  have  a  with- 
ered, senile  look.  Sometimes  the  testicles  show  signs  of  atrophy, 
being  small,  soft  and  flabby  and  having  lost  their  peculiar  sensitive- 


PARALYTIC  IMPOTENCE.  599 

ness  to  pressure,  as  well  as  being  more  or  less  unresponsive  to  elec- 
tricity; at  least  it  is  often  observed  that  the  thigh  is  much  more 
sensitive  to  the  current  than  the  testicles.  Relaxation  of  the  scrotum 
is  another  sign  which  is  sometimes  present.  Sensitiveness  of  the  penis 
to  the  electric  current  is  also  considerably  diminished.  In  many 
instances,  too,  the  sexual  impulse  is  entirely  destroyed  or  very  much 
impaired. 

In  these  cases  there  is  an  organic  change  in  the  center  of  erection 
or  in  the  paths  of  conduction.  The  exact  nature  of  this  change  has 
not  been  determined,  but  it  may  be  assumed  that  in  well- advanced  cases 
there  is  complete  degeneration  of  the  nerve-tissue.  In  others  it  is 
probable  that  there  is  only  a  partial  degeneration  or  a  temporary 
exhaustion  of  the  nerve-cells,  constituting  the  condition  known  as  atony. 

Accordingly  we  distinguish  two  subdivisions  in  this  fourth  form; 
one  with  complete  and  permanent  loss  of  sexual  power,  true  paralytic 
impotence,  the  other  with  more  or  less  serious  disturbance  of  power, 
atonic  impotence.  In  the  latter  condition  erection  occasionally 
though  rarely  takes  place,  but  it  is  usually  of  short  duration  and  is  not 
adequate  for  the  performance  of  satisfactory  coition.  Proper  treat- 
ment and  rest,  however,  may  cure  the  atony.  In  contradistinction  to 
those  who  suffer  from  true  paralytic  impotence,  those  affected  with  this 
form  may  recover  and  retain  their  virility  for  years. 

To  this  fourth  main  division  also  belong  such  cases  as  are  not 
included  in  the  other  three  groups,  namely,  those  due  to  malforma- 
tions or  defects  of  the  genitals,  mental  abnormalities,  and  excessive 
nervous  irritation. 

The  etiological  factors  in  the  fourth  group  are  excessive  venery, 
masturbation,  exhausting  general  diseases,  affections  of  the  spinal  cord 
and  brain,  and,  finally,  the  effect  of  certain  drugs. 

In  regard  to  excessive  venery  it  has  already  been  stated  that  the 
meaning  of  excess  is  difficult  to  define,  varying  with  the  individual. 
That  which  is  excessive  for  one  is  only  moderate  for  another.  The 
state  of  the  general  health  is  valuable  in  deciding  this  question,  for 
the  reason  that  with  few  exceptions  men  who  indulge  immoderately 
in  sexual  intercourse  become  weakened  and  grow  thin,  although  their 
appetite  remains  good.  The  final  result  of  extravagance  is  impotence. 
There  are  a  few  men,  however,  who  can  give  themselves  over  to 
such  pleasure  with  impunity,  but  the  number  is  very  limited. 

With  the  means  now  at  our  disposal  it  is  usually  impossible  for  us 


600  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

to  determine  just  how  continued  excesses  injure  the  organism,  and 
what  changes  they  produce.  It  is  frequently  impossible  to  detect 
any  changes;  the  patients  feel  perfectly  well,  but  nevertheless  they  are 
impotent. 

At  the  present  time  it  is  known  that  impotence  has  not  the  injurious 
results  formerly  attributed  to  it.  All  possible  diseases  were  ascribed  to 
excessive  sexual  indulgence,  whereas  it  is  very  probable  that  the  loss  of 
sexual  power  in  such  cases  was  due  to  the  general  diseases  themselves. 

It  is  true  that  extravagance  in  sexual  intercourse  generally  results  in 
emaciation,  but  in  many  cases  the  affected  persons  feel  perfectly  well. 
In  this  connection  it  is  to  be  remembered  that  excess  in  natural  coitus 
is  not  so  common  as  is  generally  believed,  for  the  simple  reason  that 
the  very  nature  of  the  thing  itself  prevents  great  excess. 

After  every  sexual  excess,  it  matters  not  how  strong  the  man,  there 
is  a  period  of  weakness  which  has  to  pass  away  before  sufficient  nerve- 
force  is  collected  to  enable  the  performance  of  the  sexual  act  again; 
desire  is  also  obtunded.  As  a  rule,  both  man  and  woman  become  more 
moderate  irrespective  of  any  intervening  external  influence.  In  the 
case  of  the  unmarried  it  is  difficulty  of  opportunity  and  other  circum- 
stances which  raise  a  barrier  before  these  over-ardent  devotees  of  Venus. 

It  is  altogether  different  in  masturbation.  Conditions  favoring 
success  are  much  better,  so  that  loss  of  bodily  strength  and  the  superven- 
tion of  impotence  are  much  more  frequently  observed. 

The  most  injurious  of  all  is  the  straining  of  an  organ  still  in  the  process 
of  development.  Sexual  excesses  cannot  be  practised  before  maturity, 
as  both  means  and  opportunity  are  absent;  masturbation,  on  the  con- 
trary, is  often  practised  in  earliest  youth.  The  effect  of  excessive 
straining  upon  the  undeveloped  sexual  organs,  such  as  results  from 
masturbation,  is  far  more  injurious  than  greater  excesses  indulged 
in  after  maturity. 

For  coitus  two  persons  are  necessary,  for  masturbation  one  is  enough. 
Therefore  it  is  clear  that  a  masturbator  will  exercise  his  sexual  organ 
oftener  than  a  person  who  has  sexual  intercourse;  the  latter  requires  a 
special  time  and  opportunity,  the  former  can  always  find  both  time  and 
opportunity.  There  are  persons  who  masturbate  while  lying  in  bed  or 
upon  a  sofa,  while  sitting,  riding  in  a  carriage,  attending  the  theatre, 
or  when  engaged  in  their  work,  and  children  who  indulge  in  it  during 
school  hours.  The  greater  the  sexual  propensities  the  oftener  is  the 
act  committed. 


PARALYTIC    IMPOTENCE.  6oi 

While  roues  are  of  gay  and  cheerful  disposition,  proud  of  their  con- 
quests, and  try  to  make  up  by  good  living  the  strength  which  they  lose 
in  debauchery,  masturbators  almost  without  exception  become  hypo- 
chondriacal as  soon  as  they  learn  that  masturbation  is  a  vice,  or  at 
least  injurious  to  the  health.  They  know  that  the  habit  is  wrong  and 
injurious  yet  they  do  not  abandon  it.  There  is  often  a  struggle  between 
the  sexual  impulse,  which  they  have  gratified  by  masturbating,  and 
their  resolve  not  to  defile  themselves.  For  a  time  the  latter  may  pre- 
vail, but  eventually  the  former  gains  the  mastery  again.  It  is  not 
surprising  when  this  conflict  is  kept  up  for  many  years,  as  I  know  it  is 
with  many  patients,  that  the  nervous  system  suffers. 

It  is  not  necessary  to  refer  again  to  the  evil  results  of  masturbation 
which  were  mentioned  in  connection  with  psychical  impotence;  that 
which  has  been  said  explains  how  long- continued  masturbation  may 
produce  atony  and  also  degeneration  of  the  centers  of  erection,  and  thus 
cause  temporary  or  permanent  impotence. 

As  concerns  further  etiologic  factors,  certain  exhaustive  constitutional 
diseases  have  been  named  as  causes  of  paralytic  or  organic  impotence. 
Severe  acute  febrile  diseases,  during  the  course  of  which  the  spermatozoa 
become  diminished  or  entirely  disappear,  will  not  be  considered  here, 
because  this  form  of  impotence  is  of  no  importance.  Exhaustion  and 
impotence  persisting  during  convalescence  are  likewise  of  no  conse- 
quence, sexual  power  almost  invariably  returning  as  strength  is  regained. 

Among  the  chronic  diseases  in  which  impotence  occurs  may  be 
mentioned  morphinism,  phthisis,  diabetes  mellitus,  obesity,  anaemia,  and 
cachexia  of  various  forms.  Diphtheria,  when  followed  by  paralysis  and 
muscular  atrophy,  also  occasionally  produces  impotence. 

I  have  never  observed  it  in  phthisis.  According  to  many  authors 
sexual  desire  and  power  is  increased  in  phthisis.  Others,  however, 
contend  that  it  is  decreased. 

It  is  certain  that  diabetes  reduces  sexual  strength;  indeed,  impotence 
often  figures  among  the  first  symptoms,  before  loss  of  bodily  strength 
occurs. 

It  is  almost  universally  believed  that  obesity  diminishes  potency. 
Although  there  is  no  rule  without  exceptions,  it  may  be  stated  that  very 
fat  persons  are  usually  more  devoted  to  Bacchus  than  to  Venus,  their 
sexual  desire  being  slight,  their  capacity  usually  deficient.  In  such 
cases  it  is  not  improbable  that  there  is  fatty  disease  of  the  testicles 
similar  to  that  which  affects  the  heart. 


602     FUNCTIONAL  DISTURBANCES  OF  THE  SEXUAL  ORGANS. 

Nothing  specific  is  known  concerning  the  influence  of  ansemia  upon 
potency. 

If  the  relations  existing  between  the  genital  organs  and  the  brain  and 
nerves  are  remembered,  it  is  not  surprising  that  impotence  often  results 
from  diseases  of  the  latter  organs.  Certain  diseases  of  the  brain  and 
cord  first  cause  increased  sexual  excitation,  which  is  followed  in  the 
latter  stages  by  weakness  and  finally  absolute  impotence. 

Thus,  in  tabes  dorsalis  sexual  desire  is  usually  first  increased  in 
consequence  of  irritation  of  the  nerve  tracts  supplying  the  sexual 
apparatus,  although  it  later  becomes  diminished  and  eventually 
entirely  disappears.  Cases  have  been  known,  however,  in  which 
advanced  tabetics  have  retained  a  high  degree  of  sexual  power. 
Injury  or  disease  of  certain  regions  of  the  brain  may  also  affect 
potency. 

The  relations  between  the  cerebellum  and  the  genital  system  are  best 
understood.  By  irritating  the  cerebellum  Budge  produced  movement 
of  the  testicle.  Concerning  this  he  writes:  " By  a  fortunate  accident  I 
made  the  surprising  discovery  that  the  testicles  of  an  old  cat,  which 
were  retained  in  the  abdomen,  moved  immediately  after  death  as  soon 
as  the  cerebellum  was  irritated  with  the  scalpel  or  caustic  potash. 
When  the  right  half  of  the  cerebellum  was  irritated  the  left  testicle 
moved,  and  vice  versa.  Even  superficial  irritation  produces  this  effect. 
The  movements  were  so  plain  that  their  reality  could  not  be  doubted. 
I  hastened  to  open  the  entire  skull  and  peritoneal  cavity  and  found  the 
testicles  absolutely  immobile ;  not  a  sign  of  motion  was  present.  As  soon 
as  one  side  of  the  cerebellum  was  irritated  the  testicle  on  the  opposite  side 
of  the  body  became  intumescent  and  moved  from  its  position  in  such  a 
manner  as  to  form  a  right  angle  with  the  vas  deferens.  When  I  stopped 
the  irritation  it  assumed  its  original  position,  and  as  soon  as  the  irritation 
was  renewed  began  to  move  again.  The  experiment  was  continued 
half  an  hour  and  always  with  the  same  result.  After  the  first  stim- 
ulus scarcely  three  seconds  elapsed  before  the  testicle  began  to  move. 
Gradually  the  interval  between  stimulation  and  reaction  became 
longer.  The  movement  lasted  only  a  short  time  and  became  weaker 
and  weaker.  I  also  irritated  the  cerebrum,  the  corpora  quadrigemina, 
the  thalami  optici  and  the  corpora  striata,  but  no  movements  of  the 
testicles  were  produced." 

A  case  bearing  on  this  observation  came  under  the  notice  of  Dr. 
Wittemore  and  was  reported  by  Dr.  Fischer.     It  was  that  of  an  old 


PARALYTIC    IMPOTENCE.  603 

man,  aged  seventy-five,  who  in  forty  years  of  married  life  had  begotten 
eleven  children.  Soon  after  his  marriage  he  began  to  complain  of 
dizziness  and  ringing  in  the  head,  from  which  he  suffered  more  or 
less  until  his  death.  In  addition  to  this  he  had  ringing  and  severe 
pain  in  the  left  ear,  together  with  difficulty  of  hearing,  as  well  as  several 
hasmiplegic  attacks  which  were  followed  by  morbidly  increased  sexual 
desire.  This  lasciviousness  partly  disappeared  three  months  before 
his  death,  so  that  he  had  a  desire  to  copulate  not  more  than  once  or 
twice  a  night.  He  was  unable  to  satisfy  his  desires,  however,  for  the 
reason  that  erection  was  imperfect,  and  emission  had  not  taken  place 
for  a  year. 

On  the  day  following  his  death  the  brain  was  examined.  The 
dura  was  adherent  to  the  skull,  the  arachnoid  thickened  and  the  pia 
very  cedematous.  The  arteries  were  calcareous.  In  other  respects 
the  brain  was  healthy  with  the  exception  of  the  cerebellum.  The 
right  lobe  was  normal,  the  left  about  one-fifth  smaller  and  having  a 
cavity  of  considerable  size  within  its  substance.  The  walls  of  this 
cavity  were  in  contact.  The  cavity  contained  serum  which  flowed  out 
when  it  was  opened. 

This  case  is  remarkable  in  that  strong  desire  was  present  which  could 
not  be  satisfied  on  account  of  defective  potency. 

Finally  certain  drugs  which  are  reputed  to  lessen  or  even  destroy 
potency  must  be  considered.  I  shall  not  discuss  the  influence  of 
riding  because  nothing  definite  is  known  in  regard  to  it. 

It  is  also  very  difficult  to  judge  the  effects  of  medicines,  for  the  reason 
that  their  action  varies  greatly  in  different  individuals  both  in  regard 
to  the  effect  produced  and  the  quantity  required.  Thus  it  happens 
that  the  most  contradictory  statements  concerning  this  subject  are 
found  in  literature. 

The  least  contention  obtains  in  regard  to  the  effects  of  strong  drink, 
which  is  generally  acknowledged  to  be  unfavorable.  It  is  a  well- 
known  fact  that  coitus  is  unsatisfactory  or  even  impossible  during 
intoxication.  This  condition  not  uncommonly  occasions  a  form  of 
psychical  impotence  depending  upon  a  feeling  of  anxiety  and  uncer- 
tainty. Constant  drinkers  suffer  from  sexual  weakness,  and  therefore 
are  prone  to  indulge  in  masturbation. 

It  is  not  certain  whether  this  action  is  due  to  the  alcohol  or  to  other 
substances  contained  in  the  liquors.  Beer  has  a  decided  retarding 
influence  upon  ejaculation  (Curschmann,  Gyurkovechky) ;  the  same 


604  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

cannot  be  said  of  wine,  for  when  taken  in  moderate  quantities  it  is 
rather  a  stimulant  and  excitant.  It  was  not  without  reason  that  the 
old  Latins  said:  Sine  Cerere  et  Baccho  jriget  Venus.  Brandy  also 
seems  to  have  a  temporary  stimulant  action  upon  the  sexual  power. 
Thus  we  must  conclude  that  strong  drink  used  in  moderation  does 
not  have  an  unfavorable  influence  upon  sexual  power;  it  is  excess 
which  is  injurious,  and  this  corresponds  to  our  knowledge  of  the 
effects  of  alcohol  in  other  respects.  It  is  known  that  alcoholic 
intoxication  impairs  the  function  of  certain  parts  of  the  brain,  so  that 
it  is  quite  possible  for  the  center  of  erection  or  the  conducting  tracts 
to  be  paralyzed  during  acute  or  chronic  alcoholism. 

Tobacco  has  a  similar  reputation.  It  was  long  since  known  as 
the  "divine  weed"  because  the  priests  often  used  it  to  dull  their 
sexual  passion.  We  have  daily  opportunities  of  witnessing  the  effect 
of  chronic  nicotine  poisoning  upon  the  nervous  system.  The  tremor 
of  the  hands  so  common  in  excessive  smokers  is  an  indubitable  nervous 
symptom.  It  is  not  permissible,  however,  to  do  more  than  consider 
the  possibility  of  an  injurious  effect  of  nicotine  upon  the  sexual  power; 
convincing  observations  have  not  been  made. 

The  action  of  morphine  is  better  understood.  According  to  Levin- 
stein it  first  increases  and  then  lessens  sexual  power.  Sexual  excitation 
and  increased  strength  almost  always  follow  an  injection  of  morphine, 
particularly  in  those  who  are  not  accustomed  to  its  use. 

Rosenthal  states  that  moderate  doses  of  morphine  (0.03  to  0.06  a 
day)  produce  cheerfulness,  loquacity,  acuteness  of  the  tactile  sense 
and  sexual  excitement,  the  latter  being  an  important  symptom  and  one 
which  is  not  generally  known. 

Opium  is  said  to  be  used  in  Persia  as  an  aphrodisiac.  This  is  in 
accord  with  the  experiences  of  opium  smokers,  who  at  first  are 
exceptionally  strong  sexually,  but  lose  their  power  of  copulation  when 
continued  action  of  the  drug  has  produced  marasmus. 

Gyurkovechy  is  of  the  opinion  that  the  primary  stimulating  effect 
is  due  to  paralysis  of  the  cerebral  centers  which  inhibit  erection. 

Many  other  drugs  are  also  supposed  to  diminish  potency,  among 
which  may  be  mentioned  lead,  antimony,  arsenic,  carbon  bisulphide, 
conium  and  camphor,  but  as  nothing  definite  is  known  concerning 
their  action  I  shall  not  discuss  them  in  detail. 

Iodine,  bromine,  salicylic  acid  and  potassium  nitrate  are  certainly 
anaphrodisiacs,  and  therefore  must  be  considered. 


PARALYTIC    IMPOTENCE.  605 

Four  cases  of  impotence  accompanied  by  more  or  less  atrophy  of 
the  testicles  are  known  to  have  developed  during  or  immediately  after 
a  course  of  iodine-inhalations  employed  in  the  treatment  of  phthisis. 
In  one  of  these  cases  desire  was  preserved  and  the  testicles  retained 
their  normal  size,  although  the  power  of  erection  was  lost.  In  the 
other  three  cases  sexual  indifference  and  atrophy  of  the  testicles  were 
both  well  marked.  The  patients  had  neither  desire  nor  power,  and 
sought  medical  advice  because  they  wished  to  perform  their  marital 
duties  and  desired  children. 

Roland  mentions  two  cases  in  which  impotence  and  atrophy  of  the 
testicles  developed  after  long- continued  use  of  potassium  iodide. 

Hammond  also  observed  diminution  of  sexual  desire  after  long  use 
of  large  doses  of  the  iodides,  but  never  knew  atrophy  of  the  testicles 
to  occur.     Desire  was  restored  after  the  drug  had  been  stopped. 

Bromine  is  known  to  be  a  quickly  acting  anaphrodisiac.  In  many 
patients  afflicted  with  frequent  pollutions  I  have  obtained  good  results 
by  administering  large  doses  of  the  bromine  salts  just  before  bedtime. 
I  generally  order  two  grammes  (thirty  grains)  of  potassium  bromide 
at  a  dose.  Persons  who  are  forced  by  nervous  disturbances  to  take 
these  salts  for  long  periods  of  time  suffer  a  diminution  of  sexual 
desire  and  power.  As  a  rule,  however,  both  return  after  the  drug  is 
discontinued. 

Concerning  salicylic  acid  Gyurkovechky  states  that  it  produces  a 
temporary  though  certain  impairment  of  virility.  He  relates  that  a 
Slavic  society  remained  away  from  a  certain  Paris  beer  saloon  because 
the  members  found  that  the  consumption  of  a  relatively  small  quantity 
of  beer  incapacitated  them  for  coitus.  Later  it  was  learned  that  the 
beer  contained  salicylic  acid.  After  this  he  investigated  the  matter 
and  found  that  more  or  less  temporary  impairment  of  potency  occurred 
during  a  course  of  salicylate  of  sodium,  a  drug  now  extensively  used. 

The  investigations  of  Kolbe  and  Lekmann  in  Munich,  though 
proving  the  harmlessness  of  the  protracted  use  of  salicylic  acid,  have 
not  contributed  anything  to  our  knowledge  of  its  action  upon  the  sexual 
power.  No  other  works  are  known  which  confirm  the  theory  that  it 
exerts  an  unfavorable  influence  upon  the  sexual  organs.  [I  have 
prescribed  salicylic  acid  and  the  salicylates  in  a  vast  number  of  cases 
and  have  yet  to  hear  a  patient  complain  that  it  impairs  his  sexual 
vigor.] 

Potassium  nitrate  is  considered  by  Hammond,  Grimmaud  de  Caux 


606  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

and  Martin  Saint  Ange  to  be  a  powerful  anaphrodisiac.  The  first 
named  author  saw  a  case  of  impotence  after  six  months'  use  of  the  drug 
in  the  treatment  of  epilepsy. 

TREATMENT  OF  IMPOTENCE. 

From  what  has  already  been  stated  it  is  seen  that  the  various  forms 
of  impotence  differ  greatly  from  one  another.  Apart  from  the  four 
groups  which  we  recognize  there  are  differences  in  the  forms  of  the 
same  group.  In  psychical  impotence  it  was  first  anxiety,  then  diversion 
of  thought,  and  again  deviation  from  normal  physiological  feeling  which 
gave  rise  to  virile  weakness.  In  irritative  nervous  impotence  both 
complete  abstinence  and  general  nervousness  were  blamed  as  causes. 

From  these  facts  it  is  seen  that  the  treatment  of  impotence  cannot 
be  routine,  but  that  it  must  be  directed  to  the  cause. 

If  it  be  due  to  deformity  of  the  external  genitals  or  neighboring  parts, 
nothing  short  of  an  operation  will  afford  relief.  Not  all  malformations 
are  remediable  by  operation,  but  there  are  certain  deformities  inter- 
fering with  coitus,  as  for  example,  those  due  to  hydrocele,  hernia, 
infiltration  of  the  urethra,  and  tumors  of  the  scrotum,  in  which  good 
functional  results  can  be  obtained  by  the  proper  operative  procedures. 

If  diabetes  be  the  cause  of  the  sexual  weakness  our  therapeutic 
measures  should  be  directed  primarily  against  this  disease.  It  is  to 
be  hoped  that  with  improvement  of  the  constitutional  disease  the 
special  disturbances  will  disappear  or  become  less. 

Although  the  cause  of  the  disease  must  always  supply  the  basis  of 
our  therapy,  the  treatment  of  impotence  may  nevertheless  be  divided 
into  psychical,  general  hygienic  and  special  medicinal. 

First,  in  regard  to  psychical  treatment,  it  will  be  remembered  that 
attention  has  already  been  directed  to  its  extraordinary  importance. 
Many  persons  suffering  from  impotence  are  timorous,  dissatisfied 
with  themselves  and  hypochondriacal.  They  often  struggle  with  a 
feeling  of  shame  and  distrust;  only  rarely  does  a  ray  of  hope  pass 
through  their  mind.  They  have  lost  confidence  in  themselves  and  in 
others.  They  think  that  nothing  can  help  them,  that  they  are  lost  for 
this  world.  Their  mind  is  constantly  occupied  with  their  disease,  and 
consequently  they  are  unable  to  concentrate  their  thoughts  upon  their 
occupation. 

This  nervous  depression  has  to  be  contended  against  above  all  things 
else,  and  it  is  the  task  of  psychical  treatment  to  do  this;  the  patient 


TREATMENT   OF    QfPOT)  Ml  i  ,  607 

must  be  made  to  take  courage,  to  acquire  confidence  in  himself  and 
hope  in  the  treatment  employed.  This  cannot  be  attained  in  any 
better  way  than  by  causing  the  patient  to  acquire  confidence  in  his 
physician.  He  must  "swear  to  the  statements  of  his  physician,"  he 
must  believe  that  which  his  physician  says  to  be  irrefutable 

How  is  the  physician  to  attain  this?  This  question  is  difficult  to 
answer;  however,  material  help  will  be  afforded  by  an  energetic 
manner,  a  careful  examination  of  the  patient,  and  the  evincement 
of  a  kindly,  active  interest  in  his  case. 

The  unfortunate  subjects  of  impotence  generally  have  no  one  in 
the  world  whom  they  trust;  they  are  ashamed  to  confide  in  their  best 
friends.  The  physician  becomes  their  father-confessor.  Even  the 
privilege  of  relating  their  trouble  somewhat  relieves  their  mind;  if 
they  find  in  the  physician  one  who  takes  interest  in  their  welfare  and 
shows  them  sympathy,  they  usually  begin  to  gain  hope.  The  nervous 
depression  yields  to  a  more  cheerful  frame  of  mind  begotten  of  hope, 
and  thus  much  is  won. 

We  have  seen  how  many  cases  of  psychical  impotence  are  caused 
by  want  of  self-confidence,  a  certain  feeling  of  anxiety.  In  such  cases 
a  cure  will  be  obtained  if  the  physician  can  restore  his  patient's  self- 
confidence.  This  cannot  be  done,  however,  by  merely  telling  him 
that  he  is  well,  that  there  is  nothing  the  matter  with  him.  Such  state- 
ments produce  the  opposite  effect.  By  diverting  the  patient's  thoughts 
from  himself,  improving  his  general  health,  and  forbidding  him  to  have 
connection  for  a  long  time  his  confidence  will  be  won  and  cure  often 
obtained. 

Psychical  treatment  must  be  adapted  to  the  patient's  range  of  thought. 
I  well  remember  a  case  of  sexual  perversion  in  which  the  patient  expe- 
rienced orgasm  only  at  the  sight  of  a  woman's  shoe.  By  having 
him  place  a  shoe  above  his  bed  and  look  at  it  during  coitus  he  was  able 
to  complete  the  act,  and  later  became  able  to  do  so  without  it. 

An  important  element  of  psychical  treatment  is  to  free  the  patient's 
mind  from  his  morbid  thoughts  and  get  him  to  think  of  something  else. 
For  this  purpose  various  amusements  are  of  use.  I  direct  those  whom 
I  do  not  send  to  a  sanitarium  to  divide  the  day  so  that  each  part  shall 
be  given  over  to  certain  diversions  or  exercises.  They  must  be  con- 
stantly engaged  in  company,  or  employed  in  some  physical  work  or 
exercise,  as  for  example,  gardening,  gymnastics,  bathing,  swimming, 
walking,  visiting  in  the  country,  or  traveling. 


608  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

This  has  the  additional  good  effect  of  keeping  them  free  from  sexual 
excitement,  which  is  beneficial  in  two  ways:  it  exerts  a  favorable 
influence  upon  the  mind,  causing  the  patient  to  think  that  his  long 
abstinence  will  strengthen  his  genitals,  and  also  increasing  sexual 
desire  and  really  resulting  in  an  accumulation  of  nervous  energy. 

Hypnotism  must  also  be  incidentally  mentioned.  Although  only 
little  is  known  in  regard  to  its  effect  upon  this  class  of  cases,  it  may  be 
reasoned  from  analogy  that  its  action  might  be  favorable.  I  do  not 
doubt  that  suggestive  treatment  may  exert  a  salutary  effect. 

Hygienic  treatment  is  a  valuable  adjunct  to  psychical. 

The  patient's  habits  of  life  must  be  so  regulated  that  his  body  will  be 
strengthened  without  the  sexual  organs  being  unduly  stimulated.  To 
this  end  diet,  baths,  sleep,  regulation  of  the  digestion,  and  physical 
exercise  require  special  consideration.  The  diet  must  be  nourishing 
but  non- stimulating;  spices  and  spiritous  liquors  in  large  quantities 
are  particularly  contraindicated. 

In  regard  to  the  latter  a  half  bottle  of  red  wine  a  day,  and  also  a  little 
cognac,  may  be  allowed,  but  too  much  drink  is  decidedly  injurious; 
for  in  that  state  of  stimulation  intervening  between  sobriety  and  intoxi- 
cation the  sexual  impulse  is  usually  aroused,  and  patients  are  then  prone 
to  break  our  rule  of  abstinence,  and,  what  is  still  worse,  masturbators 
then  relapse  into  their  old  habit.  On  the  other  hand,  a  little  wine 
stimulates  the  appetite  and  enables  the  patient  to  take  large  quantities 
of  food.  For  this  reason  wine  may  be  allowed  with  the  meals;  beer, 
however,  is  permissible  only  in  small  quantities.  I  forbid  any  to  be 
taken  for  at  least  two  hours  before  bedtime.  I  have  repeatedly 
observed  that  pollutions  occur  after  beer-drinking  late  at  night  and  that 
masturbators  are  wont  to  yield  to  their  habit  after  similar  indulgence. 

In  regard  to  food,  fat  and  substances  which  are  bulky  and  yet  contain 
but  little  nourishment  are  to  be  avoided.  Meat,  fish,  eggs,  and  a  mod- 
erate amount  of  farinaceous  food  should  form  the  principal  articles  of 
diet;  the  patient  should  not  eat  heavily,  however,  nor  at  too  late  an  hour. 
Repletion  causes  insomnia,  which  in  turn  is  apt  to  give  rise  to  erotic 
thoughts  that  may  result  in  pollutions  or  lead  masturbators  to  indulge 
in  their  habit. 

The  same  principles  underlie  the  rules  governing  sleep.  The  patient 
ought  not  to  lie  upon  a  warm  feather-bed,  nor  should  he  be  too  warmly 
covered.  A  quilt  or  blanket  will  suffice,  although  an  extra  coverlet 
may  be  placed  over  the  feet.     It  is  well-known  that  the  softness  and 


TREATMENT    OF    IMPOTENCE.  609 

warmth  of  a  feather-bed  tend  to  cause  pollutions  and  incite  masturba- 
tors  to  indulge  in  their  evil  practice. 

The  patient  should  not  sleep  upon  his  back,  but  lie  on  the  side 
instead,  because  the  former  position  tends  to  produce  emissions. 
Furthermore,  precautions  should  be  taken  to  prevent  the  patient  lying 
in  bed  too  long  with  a  distended  bladder.  Morning  erections  are  reflex 
manifestations  of  irritation  exerted  upon  the  principal  nerves  by  the 
distended  bladder.  Patients  who  have  emissions  toward  morning 
should  be  awakened  by  an  alarm-clock  an  hour  before  the  time  the 
emission  usually  occurs,  in  order  that  they  may  urinate. 

No  rule  can  be  given  in  regard  to  the  amount  of  sleep  required,  as  it 
varies  in  different  persons.  Sleep  is  a  great  restorer  of  vitality.  Eight 
hours  I  consider  the  minimum.  Many  patients,  especially  men  who 
have  lived  extravagantly,  are  accustomed  to  retire  very  late,  and  it  is 
essential  for  them  to  go  to  bed  early. 

Constipation  is  also  an  evil.  I  know  cases  of  prostatorrhcea  and 
spermatorrhoea  which  manifest  themselves  only  when  the  bowels  are 
constipated.  The  vascular  congestion  of  the  pelvic  organs  produced 
by  sluggish  bowels  acts  as  a  stimulus  to  the  sexual  organs  and  has  to  be 
combated.  Therefore  when  regular  bowel  movements  do  not  take 
place,  laxatives  in  the  most  varied  forms  possible  should  be  regularly 
used. 

Hygiene  also  includes  a  rational  activity  of  all  the  organs  and  parts 
of  the  body.  In  many  cases  it  will  not  be  necessary  to  prescribe  special 
physical  work,  as  the  daily  occupation  of  the  patient  affords  enough; 
in  others,  however,  physical  work  is  wanting  or  deficient,  or  is  of  such 
nature  that  it  develops  only  certain  parts. 

For  such  patients  gymnastics,  Swedish  movements,  massage  and 
swimming  are  of  material  benefit.  Apart  from  the  favorable  influence 
of  these  measures  upon  the  mind  they  constitute  one  of  the  best  means 
of  promoting  metabolism.  This  augmented  activity  of  the  vital  proc- 
esses ought  also  to  have  a  favorable  effect  upon  the  sexual  vigor.  The 
opposite  effect,  however,  will  be  produced  if  exercise  be  carried  too  far, 
so  that  undue  fatigue  and  lassitude  ensue.  The  fact  that  athletes 
generally  have,  or  at  least  are  considered  to  have, but  slight  sexual  power 
may  be  due  to  the  fact  that  they  overtrain. 

The  amount  of  exercise  must  be  regulated  according  to  the  indications 
in  the  individual  case;  too  little  is  better  than  too  much.  The  exercise 
must  be  of  such  a  kind  that  all  parts  of  the  body  will  be  equally  strength- 
41 


6lO  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

ened.  Walking  is  not  enough;  it  must  be  combined  with  gymnastics, 
swimming,  rowing,  etc.  The  indications  are  best  fulfilled  by  those 
forms  of  exercise  employed  in  the  mechano-therapeutic  institutes, 
because  here  attention  is  directed  in  a  systematic  manner  to  the 
individual  parts  of  the  body.  In  cases  in  which  for  any  reason  active 
gymnastics  are  not  permissible,  massage  forms  a  valuable  substitute 
for  the  promotion  of  metabolism. 

In  addition  to  those  measures  directed  to  the  mind  and  general 
health  of  the  patient,  and  which  should  always  be  considered  in  every 
case  of  impotence,  there  are  special  measures  which  are  of  service. 

Of  these  there  are  four: 

i.    Baths. 

2.  Electricity. 

3.  Local  applications. 

4.  Medicines  for  internal  use. 

I  consider  baths  to  be  one  of  the  most  important  remedies  which  we 
have  in  the  treatment  of  impotence.  They  may  be  employed  in  the 
most  diverse  forms,  as  simple  washing,  sponge  baths,  sitz-baths,  half 
and  full  baths ;  as  rubs,  douches  and  shower-baths ;  as  river,  sea  and 
brine-baths,  and  as  light  and  Roman  baths. 

Our  knowledge  of  their  effect  is  mostly  empirical.  We  can,  it  is 
true,  agree  with  Winternitz  that  the  irritation  produced  by  the  action 
of  heat  or  cold  sets  the  muscles  into  activity,  contracts  the  vessels  and 
stimulates  the  peripheral  nerves ;  the  influences  of  these  actions  upon 
the  body,  however,  have  not  been  followed  in  detail  nor  determined 
by  experimentation.  We  do  know  from  experience,  which  usually  is 
by  no  means  a  bad  teacher,  that  nearly  all  the  various  baths  mentioned 
may  be  advantageously  employed  in  the  treatment  of  impotence. 

I  consider  the  most  effectual  form  to  be  the  tepid  or  cold  full  bath 
followed  by  a  cold  douche  to  the  spine.  In  large  cities  such  baths  may 
always  be  had.  Natural  sea  baths  are  better,  as  the  impact  of  the 
waves  against  the  spine  acts  the  same  as  the  douche. 

The  mildest  form  is  simple  washing.  Similar  to  this  is  the  sponge 
bath,  a  form  which  is  often  acceptable  because  it  is  cheap  and  requires 
little  time.  Not  all  patients  have  a  bath-room  nor  means  to  visit  a 
bathing  establishment  every  day.  The  collapsible  rubber  tub,  how- 
ever, can  be  obtained  at  a  slight  cost  and  can  be  closed  and  laid  away 
after  it  has  been  used,  thus  taking  up  little  room. 

In  addition  friction  with  a  cold  wet  cloth  may  be  employed,  followed 


TRK\  I  Ml  \  I     0]      IMI'ol  I  \CE.  6]  I 

by  a  brisk  rubbing  with  a  course  towel.     This  coi  the  best 

substitute  for  the  cold  bath   in  cases  in  which  the  latter  cannot  be 
endured  or  obtained. 

Frequent  and  protracted  warm  baths  are  contraindicated  in  impo- 
tence as  they  are  weakening.  Cold  sitz-baths  of  short  duration  are  to 
be  used  only  under  certain  conditions,  as  their  action  upon  the  genitalia 
is  too  stimulating;  during  the  first  part  of  the  treatment  these  organs 
should  be  given  rest  and  not  stimulation.  Cold  baths  of  long  dur 
have  rather  a  depressing  effect. 

Exceptionally  exciting  and  stimulating  are  carbonic  acid  baths, 
and  full,  half  and  sitz-baths.  In  all  cases  in  which  the  sexual  organs 
seem  to  have  been  strained  these  baths  are  counterindicated ;  in  those 
in  which  no  weakness  is  present  they  afford  a  valuable  means  of  favor- 
ably influencing  the  mind.  I  have  seen  patients  get  a  strong  erection 
in  a  carbonic  acid  bath,  and  thereby  gain  new  courage  and  confidence. 

Natural  or  artificial  brine-baths  act  as  powerful  promoters  of  metab- 
olism, although  as  is  the  case  with  many  other  thermal  baths,  par- 
ticularly those  containing  sulphur,  their  mode  of  action  in  impotence  is 
not  thoroughly  understood. 

Electricity  in  the  form  of  galvanism,  faradism  and  Franklinization 
goes  hand  in  hand  with  baths.  Our  knowledge  of  the  action  of  this 
agent  rests  entirely  upon  experience.  We  know,  however,  that  all  three 
forms  can  be  used  with  advantage. 

The  constant  current  is  the  best.  The  parts  to  which  it  must  be 
especially  applied  are  the  spinal  column,  the  penis,  testicles  and  per- 
ineum. There  are  many  different  methods  of  applying  it,  of  which 
one  alone  or  several  in  succession  may  be  employed.  The  one  which 
I  usually  use  first  consists  in  placing  one  electrode  upon  the  left  side 
of  the  vertebral  column  and  then  running  the  other  upwards  and  down- 
wards just  to  the  right  of  the  spinous  processes;  the  order  is  then 
reversed,  the  right  being  made  stationary  and  the  left  passed  up  and  down 
along  the  spine.  The  poles  consist  of  a  wet  sponge  or  a  metal  disk 
covered  with  leather.  The  strength  of  the  current  is  determined  by 
the  sensibility  of  the  patient;  it  should  be  increased  until  a  sharp  tingling 
is  produced.  The  application  is  followed  by  redness  of  the  skin  over 
the  parts.  As  a  rule,  not  so  strong  a  current  can  be  used  upon  the 
perineum  as  upon  the  other  parts.  One  pole  is  placed  over  the 
sacral  vertebrae  and  the  other  on  the  perineum  and  allowed  to  remain 
one  or  two  minutes.     Finally  I  pass  the  constant  current  through  the 


6l2  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

penis  by  placing  one  electrode  upon  the  perineum  and  running  the 
other  along  the  anterior  and  posterior  surface  of  the  penis.  I  very 
rarely  use  the  galvanic  current  within  the  urethra.  It  has  often  been 
recommended  in  cases  of  frequent  seminal  losses  occurring  either  with 
or  without  erection.  For  this  purpose  a  bougie  having  an  electrode 
running  through  it  and  provided  with  a  conical  metal  tip  is  used.  This 
instrument  is  introduced  into  the  urethra  so  that  the  tip  lies  in  the 
prostatic  portion ;  it  is  then  attached  to  the  negative  pole  of  a  constant 
battery,  the  positive  pole,  covered  with  a  sponge,  being  placed  upon 
the  perineum,  and  a  current  of  not  more  than  five  milliamperes  turned 
on.  The  negative  pole  is  supposed  to  lessen  the  sensitiveness  of  the 
colliculus  seminalis  and  ejaculatory  ducts,  to  which  the  pollutions  are 
due. 

If  it  is  desired  to  galvanize  the  testicles  a  very  weak  current  must  be 
used  as  these  organs  are  particularly  sensitive  to  electricity.  Strong 
currents  impair  rather  than  improve  their  nutrition. 

While  the  constant  current  is  generally  employed  in  cases  where  there 
is  actual  weakness  of  the  genitals,  especially  in  paralytic  impotence, 
in  the  psychical  forms  of  the  disease  the  induction  current  is  useful. 
It  has  an  irritating,  stimulating  effect  which  is  sometimes  ocularly 
demonstrated  to  the  patient  during  its  application.  If  he  sees  an  erec- 
tion follow  an  application  of  the  induction  brush  he  is  greatly 
encouraged. 

By  means  of  a  metal  brush  the  testicles  and  especially  the  penis  can 
be  considerably  irritated.  The  sponge  is  placed  upon  the  perineum 
or  over  the  spinal  column,  while  the  brush,  attached  to  an  induction 
apparatus,  is  used  upon  the  penis.  The  glans  is  especially  sensitive. 
Therefore  the  current  must  be  increased  very  slowly.  Under  its 
influence  the  skin  becomes  reddened,  so  doubtless  stimulation  of  the 
circulation  is  produced  as  well  as  irritation  of  the  peripheral  nerves. 
I  increase  the  current  until  slight  smarting  is  produced  and  then  con- 
tinue its  application  through  the  penis  for  two  minutes.  The  procedure 
is  repeated  every  three  days.  The  results  are  very  gratifying,  particu- 
larly in  psychical  impotence. 

Many  authors  attribute  great  value  to  Franklinization. 

"The  patient  sits  upon  an  insulated  plate,  being  stripped  down  to 
the  thighs,  and  by  means  of  a  copper  sphere  sparks  are  carried  along 
the  entire  length  of  his  spine,  thus  producing  counterirritation  and 
reflex  excitation  such  as  cannot  be  elicited  by  any  other  form  of  elec- 


TREATMENT   OF    IMPOTENCE.  01 3 

tricity.  Every  spark  leaves  a  slight  elevation  upon  the  skin,  and  the 
entire  surface  is  reddened.  The  penis  is  also  often  affected  by  the 
current,  and  if  sparks  from  the  sacral  region  reach  it  ere<  tions  are  often 
produced,  even  in  cases  in  which  no  sexual  excitement  has  occurred 

for  months." 

We  now  come  to  the  consideration  of  the  so-called  local  application - 
which  are  commonly  employed,  and  which  consist  principally  in  the 
use  of  metal  sounds  and  caustic  applications  to  the  urethra. 

The  sound-cure  is  conducted  by  passing  a  sound  through  the  urethra 
every  three  or  four  days  and  allowing  it  to  remain  in  situ  for  a  few 
minutes.  To  begin  with  No.  18  F.  is  used  and  the  size  increased  up 
to  26,  or  even  28  or  30.  The  object  of  such  treatment  is  to  dull  the 
sensibility  of  the  urethra.  If  the  instrument  is  allowed  to  remain  longer 
for  a  quarter  or  half  an  hour,  an  erection  will  often  be  produced. 

Winternitz's  psychrophore  may  also  be  employed  with  advantage. 
It  is  really  a  double  current  catheter,  the  vesical  end  of  which  is  closed. 

To  the  distal  end  of  the  double  tubes  long  rubber  pipes  are  fastened, 
one  being  connected  to  a  vessel  of  cold  water  above  and  the  other  to  a 
receiving  vessel  on  the  floor.  If  the  water  now  be  allowed  to  flow  out 
of  the  jar  above,  an  uninterrupted  stream  will  pass  through  the  catheter 
in  the  urethra.  Cold  and  pressure  of  the  instrument  combine  to  exert 
a  favorable  influence  upon  the  urethra  and  the  different  organs  com- 
municating with  it.  If  it  be  desired  to  produce  erections,  warm  water 
up  to  500  C.  [122  F.]  is  more  effectual. 

Cauterization  of  the  prostatic  urethra  may  be  done  in  various  ways. 

A  very  pleasant  method  is  by  means  of  Guyon's  syringe. 

This  instrument  consists  of  a  syringe  to  which  a  hollow,  nodular- 
tipped  rubber  bougie  is  attached.  The  syringe  is  filled  with  nitrate 
of  silver  solution  (1  to  10%)  and  the  latter  is  injected  through 
the  hollow  bougie  by  turning  the  piston  around;  each  turn  fore  -  a 
drop  of  fluid  out  of  the  knob.  After  the  syringe  has  been  filled  and  the 
bougie  lubricated  the  latter  is  introduced  into  the  urethra;  at  a  distance 
of  about  14  cm.  [5I  inches]  the  knob  will  be  felt  to  enter  the  bulbous 
urethra;  by  slight  pressure  it  is  then  carried  2  cm.  [i  of  an  inch] 
onward,  whereupon  the  resistance  experienced  as  the  instrument  goes 
through  the  bulb  will  be  felt  to  subside.  After  the  membranous 
urethra  has  been  passed,  which  can  be  determined  by  rectal  palpation, 
a  drop  of  fluid  is  injected,  the  bougie  pushed  a  half  centimeter  further 
onwards    and    another    drop   injected.     In   this    manner   the   whole 


614  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

prostatic  urethra  up  as  far  as  the  internal  sphincter  of  the  bladder  can 
be  cauterized.  It  is  even  better  to  begin  at  the  vesical  sphincter  and 
make  the  application  from  within  outwards. 

This  application  is  less  painful  than  that  made  with  Ultzmann's 
syringe;  the  latter  instrument  is  used  in  the  same  way  as  Guyon's. 

Minute  rods  of  cocoa  butter  containing  nitrate  of  silver  may  be  used 
for  the  same  purpose.  They  are  applied  by  means  of  a  hollow  tube 
and  stylet. 

Thus  it  is  seen  that  methods  of  cauterizing  the  urethra  are  not  want- 
ing. I  am  of  the  opinion,  however,  that  there  is  rarely  occasion  to 
resort  to  any  of  them.  I  consider  that  they  are  indicated  and  per- 
missible only  when  there  is  inflammation  of  the  colliculus  seminalis 
and  neighboring  parts  or  when  the  prostatic  urethra  is  congested. 

The  hyperesthesia  of  the  urethra  upon  which  so  much  stress  is  gen- 
erally placed  is  really  a  trivial  matter.  Nearly  every  urethra  is  sensitive 
when  an  instrument  is  introduced  into  it.  It  is  at  least  very  difficult 
to  determine  what  degree  of  sensibility  is  normal,  particularly  as  the 
manifestations  of  pain  on  the  part  of  the  patients  when  the  same  manip- 
ulations are  practised  vary  upon  different  occasions. 

Simple  hyperesthesia  can  be  very  much  reduced  by  the  use  of  sounds, 
and  it  is  only  in  very  severe  cases  of  this  kind  that  I  would  consider  the 
application  of  a  weak  silver  solution  permissible. 

If  we  pass  now  to  the  consideration  of  internal  remedies,  there  is  a 
large  number  which  have  been  reputed  to  cure  impotence.  As  the 
reader  will  not  be  curious  to  know  about  all  which  have  been  recom- 
mended and  used,  only  well-established  facts  will  be  stated. 

Of  the  many  recognized  aphrodisiacs  I  shall  mention  cantharides, 
atropine,  phosphorus,  johimbine,  ergotin  and  strychnine.  The  sup- 
posed action  of  the  two  latter  drugs  has  frequently  been  mentioned, 
but  the  observations  are  too  few  and  not  accurate  enough  to  be 
accepted  as  positive.  The  first  four  in  the  list,  moreover,  exert  an 
irritating  action  upon  the  genital  organs. 

This  is  especially  true  of  cantharides,  which  are  given  in  the  form 
of  the  tincture  in  the  dose  of  3  to  8  drops  three  times  a  day.  An 
increased  afflux  of  blood  to  the  genitals  is  produced,  which  causes  fre- 
quent erections  and  a  pronounced  desire  to  indulge  in  coitus  or  mastur- 
bation. It  must  always  be  remembered,  however,  that  these  phenom- 
ena may  progress  to  severe  inflammation;  cases  of  strangury,  cystitis 
and  nephritis  due  to  cantharides  have  been  reported. 


TRKA  I  MEN  I    01     [MPOT]  N(  I  .  615 

In  like  manner  it  has  been  endeavored  to  explain  the  undisputed 

stimulating  action  of  phosphorus  upon  the  sexual  organs.  It  is  more 
probable  that  this  action  is  due  to  its  general  tonii  and  stimulating 
effect  upon  the  nervous  system.  The  preparations  commonly  empli 
are  phosphorus  itself  in  doses  of  0.003  L>\>  gr0  a  day,  zinc  phosphide 
in  doses  of  0.02  [§  gr.]  a  day,  and  dilute  hypophosphoric  acid  in  the  dose 
of  twenty  drops  in  water  three  times  daily.  The  dilute  phosphoric 
acid  has  less  the  action  of  phosphorus  and  therefore  is  not  to  be 
recommended.     Hammond  combined  strychnine  with  phosphorus. 

He  prescribed  100  pills  made  of 

Zinc  phosphide,  0.6.  [gr.  i] 

Ext.  of  nux  vomica,  2.0.  [gr.  xxx] 

of  which  one  is  taken  three  times  a  day ;  or  he  ordered 

Strychnini  sulph.,  0.2.  [gr.  J] 

Acid  hypophosphor.  dil.,         120.0.  [fgjv] 

Of  this  mixture  ten  drops  are  taken  in  water  three  times  a  day  and 
the  dose  gradually  increased  to  twenty-five  drops. 

Atropine  has  the  same  action  as  these  drugs.  It  causes  dilatation 
of  the  blood-vessels  of  the  genital  organs,  and,  according  to  Gross, 
relaxation  of  the  musculature  in  the  trabecular  of  the  corpora  cavernosa, 
as  the  result  of  which  more  blood  flows  into  the  penis.  Gross  also  saw 
good  results  produced  by  this  drug  in  cases  complicated  by  pollutions 
and  prostatorrhcea,  the  losses  diminishing  in  frequency  or  entirely 
ceasing.  I  have  never  observed  this  action;  on  the  contrary  I  must 
confess  that  I  believe  atropine  exerts  a  stimulating  action  on  the  gen- 
itals, which  expresses  itself  as  erections  of  increased  frequency  and 
duration.  I  order  pills  of  atropine  sulphate  containing  J  to  I  milli- 
gramme each  [approximately  v,  1 ,,  to  ,  \  „~  of  a  grain],  of  which  two  or 
three  a  day  are  taken.  If  troublesome  disturbances  of  vision  are  pro- 
duced the  drug  must  be  stopped.  More  experience  is  necessary 
before  judgment  can  be  pronounced  upon  the  recently  introduced  and 
highly  recommended  drug  johimbine. 

What  now  are  the  indications  for  the  employment  of  these  several 
drugs?  To  prescribe  them  indiscriminately  in  any  and  every  case  of 
impotence  would  not  be  rational  therapy.  In  certain  stages  of  most 
cases  they  are  even  contraindicated. 

In  organic  impotence  no  one  would  think  of  using  them;  in  irritative 
nervous  impotence  it  is  the  task  of  the  physician  to  reduce  the  irritability 
of  the  nervous  system  and  especially  that  of  the  genital  organ-:  in 


6l6  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

paralytic  impotence  the  first  requisite  for  improvement  is  a  long  period 
of  rest,  so  that  the  organs  can  regain  vigor;  in  psychical  impotence,  too, 
there  is  often  a  temporary  weakness,  so  that  it  is  well  first  to  give  the 
sexual  organs  rest  and  opportunity  to  recover  force.  During  this  time 
a  course  of  general  tonic  treatment  may  be  advantageously  employed. 
This  comprises  the  hygienic-dietetic  regimen  already  described,  to 
which  may  be  added  such  internal  roborants  as  iron  and  quinine. 
After  the  general  health  has  been  improved  and  the  tone  of  the  nervous 
system  heightened,  then  phosphorus,  atropine,  and  perhaps  canthar- 
ides  as  well,  may  be  used  as  auxiliary  remedies. 

Inhalations  of  oxygen,  which  have  been  used  by  Gyurkovechky, 
may  be  considered  to  act  in  the  same  way.  He  has  the  patient  inhale 
ten  liters  of  oxygen  at  each  sitting.  Without  presuming  to  explain 
the  action  of  these  inhalations,  he  recommends  them  most  highly  and 
attributes  to  them  a  distinct  aphrodisiac  effect;  the  latter  is  permanent, 
and  as  increase  in  bodily  strength  and  general  well-being  also  takes 
place  almost  without  exception,  it  is  probable  that  the  favorable  influ- 
ence exerted  upon  the  sexual  power  depends  upon  the  general  improve- 
ment which  is  produced.  As  yet  I  have  not  used  this  treatment,  but 
as  it  is  recommended  by  such  a  careful  observer  I  believe  it  to  be 
worthy  of  mention. 

I  must  refrain  from  criticizing  the  treatment  recently  introduced  by 
Zabludowsky,  consisting  of  methodical  massage  of  the  genital 
organs,  as  I  have  not  had  any  experience  with  it.  The  procedure 
would  seem  to  be  unpleasant  for  both  patient  and  physician.  I  will 
confine  myself  to  mentioning  his  method  of  producing  vascular 
engorgement  of  the  male  genitals.  A  tube  is  put  around  the  scrotum 
and  root  of  the  penis  and  drawn  tight,  and  the  tube  is  then  flattened 
with  a  clamp.  The  scrotum  and  penis  become  engorged.  The 
engorgement  may  be  kept  up  for  five  to  fifteen  minutes.  The  effect 
of  this  procedure  has  yet  to  be  determined. 

STERILITY  IN  THE  MALE. 

Ultzmann  has  pointed  out  the  difference  between  impotentia  catundi 
and  impotentia  generandi.  When  the  first  exists  the  latter  is  also  found 
to  be  present,  but  the  reverse  is  not  always  the  case.  It  is  well-known, 
however,  that  the  power  of  fecundation  is  not  rarely  absent  when  the 
power  of  copulation  is  preserved.  Before  passing  to  the  consideration 
of  sterility  in  the  male  I  shall  briefly  describe  the  pathology  of  the  semen. 


STERII.HA     IN      Mil.     MM. I..  M" 

The  composition  and  properties  of  normal  semen  have  already  been 
described. 

The  semen  may  vary  in  quantity.  In  healthy  men  its  quantity 
varies  under  normal  conditions  from  five  to  twenty  gramme-.  This 
quantity  may  be  diminished  or  increased.  When  the  former  i  ondition 
obtains  it  is  known  as  oligospermia,  while  the  latter  is  called  poly- 
spermia. 

The  former  is  much  more  common  than  the  latter.  The  quantity 
of  semen  is  at  times  so  small  that  only  a  few  drops  are  ejaculated.  This 
condition  is  physiological  in  old  age  and  also  occurs  in  young  persons 
as  the  result  of  various  diseases  of  the  seminal  passages.  It  is  due  to 
the  absence  of  one  or  the  other  glandular  secretions  which  are  normally 
added  to  the  testicular  secretion.  This  absence  may  be  caused  by 
alterations  in  a  certain  organ,  by  failure  of  the  organ  to  secrete,  or  by 
hindrance  to  the  outflow  of  the  secretion. 

By  hydrospermia  is  understood  an  abnormal  dilution  of  the  semen. 
If  fresh  semen  is  put  into  a  conical  glass  it  separates  into  two  layers, 
the  lower  of  which  is  the  thicker  and  the  heavier  of  the  two  and  usually 
constitutes  from  one-third  to  one-half  the  total  quantity.  If  the  semen 
is  very  thin,  this  layer,  which  is  composed  of  cellular  elements,  is  less  than 
the  upper  layer,  which  is  made  up  of  the  intercellular  fluid.  Hydro- 
spermia, then,  occurs  especially  when  few  or  no  spermatozoa  are  present. 
It  is  often  associated  with  oligospermia  and  azoospermia.  In  such 
cases  the  sperm-crystals  form  very  quickly,  often  within  half  an  hour, 
whereas  in  normal  semen  it  takes  two  or  three  days  for  them  to 
develop. 

The  color  of  normal  semen  is  grayish  white,  similar  to  that  of  boiled 
starch.  It  shows  best  on  linen,  making  a  grayish  white  stain  having 
yellow  borders  and  producing  moderate  stiffness  of  the  fabric.  If  the 
stain  is  yellow  there  is  an  admixture  of  pus  with  the  semen,  a  condition 
known  as  pyospermia.  If  the  stain  is  of  a  homogeneous  yellowish 
green  color  the  pus  is  intimately  mixed  with  the  semen;  this  occurs 
only  in  spermatocystitis.  Differing  from  this  condition  is  pyospermia 
spuria,  in  which  the  seminal  stain  is  grayish-white  with  here  and  there 
a  streak  or  spot.  This  condition  is  due  to  a  coexistent  inflammation 
of  the  seminal  or  urinary  passages.  Pus  becomes  mixed  with  the  semen 
as  the  latter  is  expelled.  The  condition  occurs  in  gonorrhoea,  cystitis 
colli  and  prostatitis.  Under  the  microscope  the  semen  oi  pyospermia 
spuria  shows  pus  cells,  molecular  debris,  epithelium  and  living  sperm- 


6l8  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

atozoa;  in  true  pyospermia  the  number  of  spermatozoa  are  small  and 
they  are  lifeless  or  malformed. 

Red  or  brownish-yellow  semen  bespeaks  the  presence  of  blood 
(hemospermia).  Like  pyospermia  this  may  also  be  true  or  spurious. 
In  the  first  instance  the  seminal  stain  is  of  a  red  to  a  chocolate-brown 
color  and  is  homogeneous,  in  the  second  isolated  blood  spots  are  dis- 
cernible upon  the  brownish-yellow  base.  Under  the  microscope 
bloody  semen  shows  blood-corpuscles,  which  are  more  or  less  altered, 
epithelium,  pigment,  granules  and  flakes,  molecular  detritus,  leucocytes, 
and  spermatozoa.  In  true  haemospermia,  which  is  caused  by  severe 
inflammation  of  the  seminal  vesicles,  spermatozoa  are  absent,  dead,  or 
malformed;  in  the  spurious  form,  which  is  almost  always  due  to  a 
violent  posterior  urethritis,  they  are  present,  and  are  usually  motile. 

Wine-colored,  violet  and  blue  semen,  which  is  mentioned  by 
Ultzmann,  is  probably  due  to  the  presence  of  indigo,  and  is  of  no  path- 
ologic significance.  Crystalline  blue  indigo  is  found  upon  micro- 
scopic examination. 

Three  forms  of  male  sterility  are  recognized:  i.  Those  cases  in 
which  physiological  semen  is  secreted,  but  owing  to  malformation  of 
the  genitals  cannot  be  discharged  into  the  vagina.  2.  Those  cases 
in  which  coitus,  though  possible,  does  not  end  with  an  ejaculation. 
3.  Those  in  which  the  semen,  though  ejaculated,  has  no  power  of 
fecundation.  This  may  be  due  to  death  of  the  spermatozoa,  or  what 
is  more  frequent,  to  their  absence.  The  first  form  is  called  sterilitas  e 
dejectu  seu  dejormatione,  the  second  sterilitas  ex  aspermatia,  or  for  short 
aspermatism,  the  third  azoospermia  (absence  of  spermatozoa). 

1.     STERILITAS  E  DEFECTU  SEU  DEFORMATIONE. 

In  this  rather  rare  form,  as  a  result  of  malformation  of  the  penis,  the 
semen  is  not  ejaculated  into  the  vagina,  but  escapes  above  or  below. 
The  most  frequent  causes  of  this  condition  are  severe  hypospadias 
and  epispadias,  and  urethral  fistulae.  It  is  only  when  the  opening 
through  which  the  semen  escapes  is  far  back  on  the  penis  that  the  power 
of  fecundation  is  lost;  even  under  these  conditions  the  semen  may 
occasionally  gain  access  to  the  vagina,  the  walls  of  the  latter  organ 
filling  in  the  defect  in  the  penis. 

Congenital  or  acquired  shortness  of  the  framum  may  produce  such 
a  deviation  of  the  penis  that  the  semen  is  ejaculated  in  a  direction 
which  prevents  its  ingress  into  the  vagina. 


ASIM.KM  \  I  ISM.  6ig 

In  such  cases  treatment  is  entirely  operative.  The  prognosis  is 
better  when  the  trouble  is  due  to  shortening  of  the  fraenum  than  when 
it  is  caused  by  hypospadias,  epispadias,  or  urethral  fistula. 

2.     ASPERMATISM. 

In  this  condition,  as  has  already  been  stated,  the  semen  is  formed, 
but  is  not  carried  out  of  the  body  through  the  genital  and  urinary 
passages.  We  distinguish  an  absolute  or  permanent  and  a  relative 
or  temporary  aspermatism. 

Absolute  aspermatism  may  be  congenital  or  acquired.  In  the 
former  case  ejaculation  has  never  occurred,  in  the  latter  it  has  ceased 
to  take  place.  The  cause  in  these  cases  is  always  an  organic  lesion, 
which  may  be  located  anywhere  from  the  seminal  vesicles  to  the  external 
urethral  orifice.  According  as  the  lesion  can  or  cannot  be  removed 
the  aspermatism  is  permanent  or  temporary. 

Temporary  or  relative  aspermatism  is  characterized  by  the  fact 
that  ejaculation  occurs  only  occasionally  or  under  certain  conditions, 
failing  to  take  place  at  other  times  or  under  other  circumstances. 

This  form  of  sterility  may  depend  upon  lesions  of  the  urinary  and 
seminal  passages,  non-irritability  of  the  ejaculatory  center,  anaesthesia 
of  the  peripheral  genital  nerves,  or  inhibitor}'  action  of  the  brain  upon 
the  ejaculatory  center.  The  forms  of  relative  aspermatism  accordingly 
are  one  due  to  insufficiency  of  the  genital  organs,  an  atonic,  an  anaes- 
thetic, and  a  psychical. 

That  semen  has  never  entered  the  urethra  nor  escaped  therefrom 
during  coitus,  is  a  condition  which  may  be  due  to  various  causes,  the 
recognition  of  which  is  of  diagnostic  and  particularly  prognostic 
value. 

The  cases  in  which  there  is  congenital  occlusion  or  absence  of  the 
ejaculatory  ducts  or  deviation  in  their  opening  into  the  urethra  are  very 
rare.  Cases  of  this  kind  have  been  reported  by  Munroe,  Rindfleisch 
and  Klebs. 

Acquired  obstruction  and  deviation  of  the  ejaculatory  ducts  are  more 
common. 

Demeaux  reports  the  case  of  a  healthy  man  aged  twenty-two  years, 
who  as  the  result  of  a  fall  upon  his  perineum  developed  an  abs 
which  necessitated  incision.     A   few   months   afterwards   the   patient 
noticed  that  coitus  no  longer  ended  with  a  discharge  of  seminal  fluid. 


620  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

Although  there  was  no  stricture  of  the  urethra,  urine  voided  after 
connection  was  heavily  loaded  with  spermatozoa.  Upon  rectal 
palpation  it  was  found  that  the  perineum  was  contracted  and  the 
prostate  drawn  down,  which  led  Demeaux  to  conclude  that  the  ori- 
fices of  the  ejaculatory  ducts  had  become  displaced  backwards  as  the 
result  of  the  injury. 

Gonorrhoea  may  also  cause  aspermatism,not  only  by  leading  to  the 
formation  of  urethral  stricture,  which  will  be  discussed  later,  but  also 
by  advancing  into  the  ejaculatory  duct  and  producing  thickening  and 
contraction  of  its  walls,  and  by  producing  alterations  in  the  surrounding 
tissues  which  lead  to  obliteration  of  the  ducts. 

Hypertrophy  of  the 'prostate,  prostatic  calculi,  fibrous  degeneration, 
tuberculous  ulcerations,  stones  and  concretions  in  the  ejaculatory  ducts, 
trauma,  or  injury  inflicted  during  an  operation,  may  likewise  lead  to 
occlusion  or  narrowing  of  the  ducts. 

In  regard  to  concretions  they  may  develop  as  the  result  of  inflam- 
mation, the  pus  becoming  thick  and  cretaceous,  or  they  may  be 
formed  out  of  dead  spermatozoa,  mucus  and  epithelium,  with  a  de- 
posit of  inorganic  elements. 

Examples  of  injury  to  the  ejaculatory  duct  inflicted  in  lateral  or 
bilateral  lithotomy  which  have  resulted  in  aspermatism  have  been 
cited  by  Gross  and  Teevan. 

The  formation  of  a  fistula  between  the  seminal  vesicles  and  rectum 
which  led  to  aspermatism  has  followed  a  recto-vesical  lithotomy.  In 
Sabatier's  case  ejaculation  took  place  into  the  rectum. 

Covillard's  case  is  even  more  remarkable;  vesical  calculi  passed 
through  fistulae  in  the  perineum  and  down  the  inner  side  of  the  thigh, 
and  the  semen  also  followed  this  course. 

All  the  cases  thus  far  mentioned  which  depended  upon  organic  lesions 
were  alike  in  that  the  semen  did  not  enter  the  urethra,  or  at  least  did 
not  reach  that  portion  of  it  situated  anteriorly  to  the  prostatic  part. 
'\We  now  come  to  that  form  of  aspermatism  in  which  the  semen  enters 
the  urethra  but  does  not  flow  out  of  it.  Here  there  is  a  congenital  or 
acquired  narrowing  of  the  urethra.  A  further  point  of  differentiation 
between  this  class  of  cases  and  those  previously  described  is  afforded 
by  the  fact  that  the  obstruction  can  be  overcome,  the  aspermatism 
consequently  being   curable. 

Gonorrhoea  is  recognized  as  the  most  frequent  cause  of  acquired 
urethral  stricture.     Doubtless  the  number  of  strictures  causing  reten- 


ASPERMATISM.  62 1 

tion  of  the  semen  is  few,  although   I  have  seen  several  myself  and 
others  have  been  reported. 

As  strictures  nearly  always  are  permeable  to  the  urine — cases  of 
complete  retention  are  not  considered  as  they  have  no  bearing  upon 
aspermatism — it  may  be  assumed  that  they  will  also  permit  the  passage 
of  the  seminal  fluid.  This  assumption,  however,  is  not  correct.  The 
stricture  may  allow  urine  to  pass  through  and  yet  be  impermeable 
for  the  semen.  The  conditions  for  ejaculation  are  different  than  those 
for  micturition. 

Semen  is  thicker  than  urine  and  the  pressure  which  it  exerts  is  less 
than  that  of  the  stream  of  urine;  it  is  also  conceivable  that  the  stricture 
may  be  more  yielding  when  the  penis  is  flaccid  than  when  it  is  erect. 
The  scar-tissue  may  be  deposited  in  such  a  manner  that  the  shape  of 
the  stricture  is  changed  when  erection  occurs,  with  the  result  that  it 
becomes  less  permeable. 

By  analogy  the  occurrence  of  spasm  of  the  urethral  musculature  may 
be  assumed  in  explanation  of  the  condition.  It  is  known  that  many 
strictures  are  permeable  one  day  and  impermeable  the  next.  In  such 
cases  it  is  not  that  the  lumen  of  the  urethra  has  become  so  much  smaller 
over  night,  but  that  muscular  spasm,  a  spastic  stricture  so  to  speak, 
has  been  superimposed  upon  the  organic  lesion.  This  is  an  occurrence 
which  every  surgeon  has  often  observed,  and  from  which  it  follows 
that  the  stricture  may  be  permeable  again  for  days  at  a  time.  In  like 
manner  retention  of  semen  may  often  be  due  to  spasm  superimposed 
upon  stricture. 

Those  cases  in  which  the  semen  fails  to  be  ejaculated,  although  the 
caliber  of  the  urethra  is  comparatively  large,  are  to  be  conceived  as  due 
to  this  cause. 

To  these  are  added  those  cases  of  phimosis  which  lead  to  retention 
of  semen. 

Concerning  the  treatment  of  these  cases  there  is  nothing  to  be  said 
except  about  those  depending  upon  stricture  of  the  urethra  and  phi- 
mosis. The  appropriate  operative  procedures  arc  self-evident.  Cir- 
cumcision, dilatation  of  strictures,  and  reduction  of  urethral  hyper- 
sensibility  in  cases  where  spasm  superimposed  upon  stricture  causes 
retention  of  semen  will  almost  always  effect  a  cure.  The  dulling  of 
hyperaesthctic  portions  of  the  urethra  may  be  secured  by  the  repeated 
introduction  of  large  metal  sounds  or  by  instillations  of  mild  a>tringents 
or  weak  caustics. 


62  2  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

ATONIC  ASPERMATISM. 

In  contradistinction  to  the  forms  of  aspermatism  previously  described, 
the  causes  of  which  depend  upon  defects  in,  or  impermeability  of,  the 
seminal  passages,  the  form  now  to  be  discussed  is  due  to  non-irrita- 
bility of  the  ejaculatory  center  situated  in  the  spinal  cord.  This  non- 
irritability  prevents  coitus  from  being  completed  in  the  normal  manner, 
although  the  patients  are  generally  potent,  erection  being  good  and  of 
sufficient  duration,  sexual  impulse  normal,  and  intercourse  pleasurable. 
It  is  remarkable  that  men  thus  affected  often  have  nocturnal  pollutions 
which  occur  both  with  and  without  voluptuous  sensation. 

This  occurrence  is  due  to  the  fact  that  when  the  seminal  vesicles 
become  distended  with  a  certain  amount  of  semen,  they  contract  as 
the  result  of  the  mechanical  irritation  thus  produced  irrespective  of  any 
irritation  in  the  central  nervous  system. 

This  atonic  aspermatism  may  be  congenital  or  acquired;  the  latter 
is  much  more  common.  In  the  congenital  cases  the  ejaculatory  center 
in  the  cord  is  non-irritable  ab  origine;  in  the  acquired  cases  its  irritability 
has  been  lost  in  consequence  of  certain  causative  conditions,  with  the 
cessation  of  which  the  tonicity  of  the  center  is  restored. 

Accordingly  the  acquired  cases  are  often  curable  if  the  causative 
factors  can  be  removed. 

Chief  among  these  causes  are  excesses  in  venery .  As  in  psychical  impo- 
tence, so  likewise  here,  masturbation  has  a  more  injurious  effect  than 
immoderate  sexual  intercourse.  The  reasons  for  this,  as  already  stated, 
are  that  masturbation  can  be  practised  more  frequently  than  even  the 
most  wanton  excess  and  that  the  nervous  excitement  occurring  in  mas- 
turbation is  greater  than  that  incident  to  copulation.  This  is  also 
shown  by  the  fact  that  the  general  relaxation  of  the  body  is  greater 
after  masturbation  than  after  coitus.  It  may  also  be  assumed  that 
the  central  nerve- cells,  however  well  they  may  be  regenerated,  may  in 
time  become  so  weakened  as  the  result  of  abuse  that  the  usual  stimuli 
no  longer  suffices  to  arouse  them. 

The  congenital  cases  are  not  amenable  to  treatment ;  in  the  acquired 
cases  we  have  seen  that  the  cause  is  attributable  to  too  great  demands 
upon  the  ejaculatory  center.  The  most  effective  remedy  is  rest; 
accordingly  a  long  period  of  abstinence  from  sexual  intercourse  must 
be  enjoined  upon  patients  of  this  class,  and  a  generous  diet,  together  with 
a  hygienic  regimen,  prescribed  in  order  to  build  up  the  general  health. 

Patients    suffering   from   general   neurasthenia   require    the    usual 


ANAESTHETIC    ASPERMATISM.  623 

nervines  and  suggestive  treatment  described  in  the  article  on  the 
treatment  of  impotence;  if  there  is  hyperesthesia  of  the  urethra,  local 
measures,  such  as  the  injection  of  slightly  cauterant  drugs  and  the 
introduction  of  metal  sounds,  are  indicated. 

ANAESTHETIC  ASPERMATISM. 

A  few  rare  cases  of  aspermatism  may  be  referred  to  sensory  disturb- 
ances in  the  skin  of  the  penis,  as  the  result  of  which  the  reflex  action 
of  the  peripheral  nerves  upon  the  ejaculatory  center  is  rendered 
impossible.  It  has  been  attempted  to  demur  to  this  theory  by  attribu- 
ting the  nocturnal  pollutions  to  purely  psychical  irritation  of  the  nervous 
center  occurring  independently  of  peripheral  irritation.  Nocturnal 
emissions  have  been  known  to  occur  in  anaesthesia  of  the  penis,  but 
they  are  doubtless  due  to  purely  mechanical  irritation  caused  by 
distention  of  the  seminal  vesicles. 

Ulceration  and  scar-formation  on  the  penis  may  lead  to  the  same 
result.     Absence  of  sensibility  of  the  penis  may  also  be  congenital. 

When  the  condition  is  acquired  an  attempt  may  be  made  to  restore 
the  lost  sensibility  by  means  of  the  faradic  current. 

PSYCHICAL  ASPERMATISM. 

If  psychical  aspermatism  is  spoken  of,  it  must  be  granted  that  the  mind 
can  influence  ejaculation  as  well  as  erection.  This  influence  is  revealed 
by  the  fact  that  many  men  are  able  to  retard  ejaculation  at  will.  It 
was  this  method  which  the  adherents  of  Malthus  practised  in  coitus 
interruptus,  and  one  which  is  also  made  use  of  by  sensualists  for  the 
purpose  of  prolonging  the  pleasure  of  intercourse. 

It  is  also  known  that  ejaculation  may  occur  only  during  intercourse 
with  certain  women,  just  as  in  psychical  (relative)  impotence  coitus 
can  be  practised  only  with  certain  women;  as  in  the  latter  so  in  the 
former,  aversion,  suspicion  of  infidelity,  in  short,  psychical  influences, 
are  the  causes  which  prevent  the  occurrence  of  emission. 

Reasoning  still  further  by  analogy  it  may  be  assumed  that  the 
inhibitory  center  in  the  brain  is  so  stimulated  by  mental  impressions 
that  it  sends  forth  an  impulse  suppressing  the  activity  of  the  ejaculatory 
center. 

The  removal  of  this  condition  lies  without  the  realm  of  medical 
practice. 


624  FUNCTIONAL    DISTURBANCES    OF   THE    SEXUAL   ORGANS. 

The  diagnosis  of  aspermatism  is  self-evident.  From  what  has 
already  been  said  it  is  also  evident  that  the  differentiation  between  the 
various  forms,  which  is  important  from  the  standpoint  of  prognosis 
and  treatment,  is  not  at  all  difficult. 

AZOOSPERMIA. 

In  azoospermia,  as  in  aspermatism,  the  power  of  copulation  is  usually 
not  weakened,  although  in  contradistinction  to  the  latter  coitus  ends 
with  an  ejaculation.  Notwithstanding  this,  however,  the  subjects  of 
azoospermia  are  sterile  for  the  reason  that  their  semen  has  lost  its 
power  of  fecundation. 

Generally  speaking  the  criterion  of  fecundity  consists  in  the  pres- 
ence or  absence  of  spermatozoa  in  the  semen ;  furthermore,  it  is  to  be 
observed  whether  they  are  inactive  or  dead  or  whether  they  soon  die. 

The  following  conditions  are  recognized  as  the  principal  causes  of 
azoospermia :  the  organs  which  produce  the  spermatozoa  are  absent  or 
their  function  is  destroyed;  the  semen  may  be  rendered  unfruitful  by  dis- 
ease of  the  seminal  passages;  the  semen,  though  normally  produced, 
may  be  prevented  from  passing  out  of  the  body  by  anomalies  of  the 
genital  passages;  finally  severe  constitutional  disease  may  undermine 
the  strength  of  the  generative  organs. 

Absence  of  both  testicles,  anorchism,  of  course  precludes  the  possi- 
bility of  fecundation. 

If  the  absence  of  the  testicles  is  not  congenital,  being  acquired  during 
adult  life,  the  individual  may  retain  the  power  of  copulation  for  a  time, 
although  the  power  of  procreation  is  extinguished  when  the  testicles 
are  lost. 

Bilateral  absence  of  the  testicles  affects  the  entire  organism.  The 
individuals  are  different  in  appearance,  character  and  habit;  they  have 
no  sexual  desire  and  no  voluptuous  feeling,  being  similar  to  eunuchs 
who  were  mutilated  in  the  early  years  of  life. 

Unilateral  anorchism  does  not  destroy  the  power  of  fecundation, 
provided  the  second  testicle  is  healthy  and  no  other  anomalies  are 
present  to  alter  the  fertility  of  the  semen. 

Cryptorchidism,  a  condition  in  which  one  or  both  testicles  do  not 
lie  in  the  scrotum,  but  are  abnormally  situated,  although  more  common 
than  anorchism  is  nevertheless  comparatively  rare. 

It  is  not  always  easy  to  decide  whether  the  testicles  are  absent  or 
abnormally  placed.     As  a  rule,  they  can  be  felt  in  the  inguinal  canal, 


AZOOSPERMIA.  625 

iliac  fossa,  or  crural  canal,  but  if  they  arc  within  the  abdomen  the 
appearance  and  habits  of  the  patients  must  be  taken  into  considera- 
tion in  making  a  differential  diagnosis. 

Unilateral  cryptorchidism  never  causes  sterility  unless  some  other 
anomalies  arc  also  present.  Opinions  differ  in  regard  to  the  effect  of 
bilateral  exstrophy  of  the  testicles. 

The  literature  on  the  subject  shows  that  cryptorchidism  does  not 
always  result  in  sterility.  This,  however,  does  not  mean  that  crypt- 
orchids  are  not  often  sterile,  a  fact  which  evidently  depends  upon  the 
pathic  changes  which  have  occurred  in  the  testicles  as  the  result  of  their 
malposition.  They  are  usually  small,  undeveloped,  atrophied  and 
affected  •  with  fatty  or  fibrous  degeneration.  The  fecundating  power 
of  the  semen  depends  upon  the  degree  of  degeneration  present.  Defin- 
itive information  can  be  secured  only  by  microscopic  examination  of 
the  semen. 

Certain  diseases  of  the  testicles  may  also  result  in  diminution  or 
destruction  of  the  fecundating  power  of  the  semen.  If  both  testicles 
are  destroyed  by  disease,  permanent  azoospermia  is  the  result ;  in  cases 
in  which  the  disease  can  be  cured  the  azoospermia  is  only  temporary; 
in  others  the  function  of  the  testicles  is  not  entirely  destroyed  but  is 
weakened.  The  result  is  that  only  a  few  spermatozoa  are  produced. 
This  condition  is  called  oligospermia  (Ultzmann). 

The  most  common  cause  of  lessened  functional  capacity  of  the  testicle 
is  atrophy.     It  may  depend  upon  a  variety  of  causes. 

In  the  first  place  there  are  testes  which  may  be  designated  as  undevel- 
oped. Here  we  have  to  do  with  malformations  due  to  arrest  of  develop- 
ment, which  are  of  rare  occurrence,  although  they  occasionally  affect 
the  testicles  the  same  as  other  organs.  The  entire  sexual  apparatus 
usually  shares  in  the  non-development;  the  external  organs  are  of  the 
appearance  and  size  of  those  of  a  child. 

Of  greater  importance  are  the  atrophies  which  are  due  to  demon- 
strable causes.  As  such  are  recognized  lesions  of  the  central  nervous 
system  and  inflammation  or  continued  compression  of  the  testicles. 

Exceedingly  rare  arc  degenerations  due  to  disease  of  the  nerve-tracts. 
Such  disease  may  affect  the  spinal  cord,  particularly  the  lumbar  region, 
where  the  centers  of  erection  and  ejaculation  are  situated,  and  also  the 
brain.  In  addition  to  clinical  observations,  experiments  prove  that 
atrophy  of  the  testicles  may  follow  injury  to  certain  portions  of  the  brail) 
and  cord. 
42 


626  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

Inflammation  of  the  substance  of  the  testicle,  no  matter  what  variety 
it  be,  may  also  be  followed  by  atrophy.  Although  gonorrhoea  usu- 
ally attacks  the  epididymis,  it  has  been  known  to  invade  the  testicle. 
Trauma  is  one  of  the  most  frequent  causes.  Simple  catheterization 
may  give  rise  to  orchitis;  metastatic  orchitis  accompanying  parotitis  is 
very  frequent,  and  it  is  important  to  remember  that  there  are  cases  of 
parotitis  without  orchitis,  and  vice  versa. 

In  the  majority  of  cases  the  function  of  the  testicle  is  restored 
after  the  inflammatory  process  subsides.  Occasionally,  however,  the 
inflammation  is  followed  by  fibrous  degeneration  of  the  parenchyma 
of  the  gland,  which,  according  to  whether  one  or  both  testicles  are 
involved,  and  also  to  the  degree  of  inflammation,  leads  to  oligospermia 
or  azoospermia,  and  consequently  to  complete  sterility. 

Finally,  as  concerns  atrophy  of  the  testicles  due  to  compression,  it  is 
necessary  for  ,the  pressure  to  be  of  considerable  intensity  and  of  long 
duration.  Such  pressure  may  be  produced  by  large  hydroceles,  scrotal 
hernias  and  varicoceles. 

Among  other  diseases  of  the  testicles  which  may  result  in  sterility 
are  syphilis,  carcinoma  and  tuberculosis. 

The  most  favorable  prognosis  is  afforded  by  syphilis.  Both  testicles 
are  usually  affected,  but  unless  the  gummatous  degeneration  be  too  far 
advanced  antisyphilitic  treatment  will  restore  their  function. 

Carcinoma  more  often  results  in  oligospermia,  for,  as  a  rule,  it  is 
circumscribed  and,  moreover,  generally  affects  only  one  testicle,  so 
that  sufficient  healthy  parenchyma  remains.  The  same  is  true  of 
tuberculosis. 

In  the  cases  due  to  absence  or  occlusion  of  the  epididymis  and  vas 
deferens  the  testicles  are  healthy,  but  owing  to  the  former  condition 
the  semen  cannot  be  carried  to  the  seminal  vesicles. 

If  there  is  congenital  absence  of  epididymis  and  vas  deferens  on 
both  sides,  the  fluid  ejaculated  during  coitus  naturally  cannot  contain 
spermatozoa. 

The  same  effect  is  produced  by  acquired  occlusion  of  the  spermatic 
ducts.  If  the  epididymes  are  attacked  by  inflammation  complete 
obliteration  of  the  ducts  not  uncommonly  results.  It  is  immaterial 
from  what  cause  the  inflammation  develops;  the  result  is  the  same. 
All  depends  upon  the  degree  and  the  extent  of  the  inflammation. 

As  injury  to  the  epididymis,  syphilis,  tuberculosis,  carcinoma  and 
sarcoma  are  rare,  and  their  bilateral  occurrence  still  rarer,  they  are  not 


AZOOSPERMIA.  627 

of  great  importance,  particularly  in  comparison  with  the  most  frequent 
cause  of  sterility,  namely,  gonorrhceal  epididymitis. 

Even  though  it  be  an  exaggeration  to  state  that  "absolute  impoten<  e 
results  when  both  epididymes  are  attacked  by  gonorrhoea"  (Sanger), 
it  is  unfortunately  true  that  this  complication  often  leads  to  azoospermia. 
Out  of  eighty-three  men  affected  with  bilateral  epididymitis  Liegeois 
found  spermatozoa  in  the  semen  of  only  eight.  I  have  very  fre- 
quently observed  sterility  in  men  who  have  had  double  epididymitis. 

Unilateral  inflammation  causes  a  decrease  in  the  number  of  sperma- 
tozoa, an  oligospermia. 

This  well  shows  what  a  serious  disease  epididymitis  is.  It  makes  it 
necessary  for  us  to  treat  every  case  of  epididymitis  most  carefully,  and 
above  all  things  to  endeavor  to  limit  its  extension  as  much  as  possible. 

If  any  portion  of  the  seminal  passage,  by  which  term  is  meant  the 
entire  tract  from  the  testicle  to  the  external  urethral  orifice,  becomes 
inflamed,  the  products  of  inflammation  mingle  with  the  semen.  In 
epididymitis,  inflammation  of  the  vas  deferens,  spermatocystitis,  pros- 
tatitis and  gonorrhoea,  the  semen  contains  pus-cells  and  perhaps  blood- 
corpuscles.  As  far  as  sterility  is  concerned  it  is  only  those  processes 
in  which  the  admixture  diminishes  or  destroys  the  vitality  of  the  sper- 
matozoa which  are  of  importance. 

During  the  acute  stage  of  the  above  named  affections  it  is  imma- 
terial whether  the  spermatozoa  are  destroyed  at  the  seat  of  the  disease 
or  not,  although  after  the  disease  has  lasted  longer  it  is  of  interest  in 
respect  to  the  general  condition. 

A  much  discussed  question  now  arises,  namely,  "what  is  the  action 
of  pus  upon  spermatozoa?"  Many  investigators  state  that  the  latter 
are  killed  by  pus-cells  or  the  microorganisms  which  are  present  with 
them. 

On  the  other  hand,  it  has  often  been  observed  that  patients  who  have 
had  unilateral  or  even  bilateral  epididymitis,  chronic  prostatitis,  or 
gonorrhoea  not  only  produce  semen  containing  active  spermatozoa,  but 
that  they  actually  beget  children. 

What  is  the  meaning  of  this?  How  can  these  observations  be  har- 
monized ? 

The  numerous  cases  of  prostatitis  and  epididymitis  in  which  admix- 
ture of  pus  and  semen  takes  place  and  fecundation  nevertheless  occurs 
prove  that  pus  is  not  always  deleterious  to  the  spermatozoa.  At  times, 
however,  it  may  reduce  or  completely  destroy  their  vitality.     In  many 


628  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

cases  this  may  be  due  to  the  thickness  of  the  fluid  produced  by  the 
admixture  of  pus.  A  case  has  been  reported  by  Beigel  in  which  the 
semen  was  extraordinarily  thick  and  the  spermatozoa  motionless  and 
close  together;  upon  the  addition  of  lukewarm  water  they  became 
motile.  Warm  water  was  also  injected  into  the  vagina  to  dilute 
the  semen,  with  the  result  that  conception  occurred.  This  case  is 
an  exception,  for  suppuration  is  rarely  so  profuse  as  to  produce  such 
a  degree  of  thickening  in  the  semen. 

For  this  reason  I  maintain  with  Fiirbringer  that  pus,  although 
exerting  an  unfavorable  influence  upon  the  spermatozoa,  does  not 
destroy  them  nor  render  the  semen  unfertile. 

Conditions  are  exactly  the  same  in  hemospermia. 

Blood  itself  does  not  destroy  the  spermatozoa.  Robin  has  shown 
that  they  may  live  in  it  four  or  five  hours.  One  often  has  occasion  to 
examine  bloody  semen  which  is  ejaculated  during  the  course  of  posterior 
urethritis,  cystitis  colli  or  prostatitis.  The  number  of  spermatozoa 
is  generally  diminished;  a  few  are  lifeless  or  inactive,  the  majority, 
however,  are  apparently  normal. 

THE    RELATION    OF   GENERAL   DISEASES   TO    AZO- 
OSPERMIA. 

Physiological  Azoospermia.  That  alterations  in  the  general 
health  may  influence  the  secretory  activity  of  the  testicles  is  best  shown 
by  physiological  or  temporary  azoospermia.  By  this  term  is  meant 
the  secretion  of  a' semen  in  which  spermatozoa  are  absent  at  times  and 
present  at  others. 

It  has  long  been  known  that  the  frequency  of  ejaculation  has  a  great 
influence  upon  the  composition  of  the  semen.  The  oftener  it  is  dis- 
charged within  a  given  time  the  less  its  quantity  and  thinner  its  con- 
sistency, whereby  the  number  of  spermatozoa  become  less  and  less. 
Finally  it  consists  of  the  secretion  of  the  accessory  genital  glands. 

Liegeois  mentions  the  case  of  a  medical  student  who  had  connection 
three  or  four  times  a  day  for  ten  days  in  succession,  and  whose  semen 
upon  repeated  examination  failed  to  show  spermatozoa.  After  three 
weeks  of  abstinence  from  sexual  intercourse  they  were  found  in  abun- 
dance. 

A  similar  case  reported  by  Casper  (the  medico-legal  expert)  is  that 
of  a  naturalist  aged  sixty,  who  examined  his  semen  microscopically 


THE    RELATION    OF    GENERAL    DISEASES    TO    AZOOSPERMIA.       629 

with  Casper  for  a  long  period  of  time.  It  was  found  that  it  became 
more  fluid  and  poorer  in  spermatozoa  the  oftener  coitus  was  indulged 
in.  If  he  had  connection  on  two  successive  days  no  spermatozoa  were 
present;  after  abstaining  for  three  days  the  ejaculate  contained  sperm- 
atozoa in  abundance,  although  they  were  small;  on  the  day  after  they 
were  small  and  few  in  number.  After  five  days  of  rest  they  appeared 
in  abundance,  and  an  interval  of  six  days  produced  few  though  large 
spermatozoa. 

Thus  it  may  happen  that  a  man  who  is  fully  potent  and  in  possession 
of  his  fecundating  power  may  become  temporarily  sterile.  This  is  a 
matter  of  practical  importance.  It  explains  why  many  men  whose 
potentia  cceundi  et  generandi  are  absolutely  normal  fail  to  beget  children. 
The  reason  is  that  they  have  connection  too  often.  This  physiological 
azoospermia,  therefore,  is  especially  common  among  very  sensual  men. 

It  is  interesting  to  note  that  experiments  upon  animals  confirm  these 
observations.  Plonnies  proved  that  frequent  ejaculations  produced  in 
dogs  by  electrical  stimulation  of  the  spinal  cord  brought  about  dim- 
inution in  both  quantity  and  quality  of  the  semen;  the  spermatozoa 
are  often  entirely  absent. 

Sexual  Neurasthenia.  These  considerations  lead  us  to  that  form 
of  azoospermia  which  develops  in  certain  forms  of  neurasthenia,  and 
which  is  to  be  regarded  as  an  augmentation  of  the  transitory  physio- 
logical form  just  described.  Masturbators  and  men  who  have 
indulged  excessively  in  coitus  constitute  the  chief  contingent  of  sexual 
neurasthenics.  One  of  the  most  constant  symptoms  of  this  disease  is 
nocturnal  pollutions,  or  even  spermatorrhoea. 

There  are  also  various  associated  phenomena  on  the  part  of  the 
nervous  system  and  mind,  as  well  as  disturbances  of  nutrition. 

If  the  semen  of  a  man  thus  affected  be  examined,  it  will  not  uncom- 
monly show  signs  of  azoospermia,  oligospermia,  or  changes  in  the 
spermatozoa— conditions  which  indicate  that  there  is  impairment  of  the 
power  of  fecundation. 

The  principal  alterations  in  the  spermatozoa  are  impairment  of 
motility  and  low  vitality;  they  soon  die.  It  has  not  been  positively 
determined  whether  changes  in  their  form,  such  as  kinking  and  coiling 
of  the  tail,  noticed  by  Ultzmann,  and  swelling  of  the  head,  observed 
by  Neumann,  are  pathologic  changes.  It  is  certain,  however,  that 
impairment  of  nutrition  and  disturbances  of  the  nervous  system, 
and  above  all  things  undue  demands  upon  the  secreting  organs,  may 


630  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

lead  to  grave  disturbances  in  the  nutrition  and  innervation  of  the 
testicles,  and  consequently  to  the  production  of  a  semen  deficient  as 
to  quantity  and  quality. 

Syphilis.  A  constitutional  disease  in  which  azoospermia  occasion- 
ally occurs  is  syphilis.  It  need  scarcely  be  stated  that  syphilitic 
orchitis  and  gummata  of  the  testicles  are  not  referred  to,  because  in 
these  conditions  the  entire  glandular  substance  is  destroyed,  so  that 
no  semen  can  be  secreted,  or  else  the  lesion  is  circumscribed  so  that 
enough  healthy  tissue  remains  to  secrete.  It  is  only  constitutional 
syphilis  without  localized  lesions  in  the  testicles  which  will  be  discussed. 

This  form  of  the  disease  produces  azoospermia  in  many  cases, 
although  in  others  living  spermatozoa  are  found  (Gross  and  Bryson). 
Demonstration  of  the  latter  fact  is  scarcely  necessary,  as  the  numerous 
children  affected  with  hereditary  syphilis  who  are  born  of  healthy 
mothers  prove  that  syphilitic  men  retain  their  power  of  procreation. 
Zeissl,  however,  states  that  he  has  known  several  men  who  had  had 
syphilis,  who  although  of  strong  constitution,  were  unable  to  beget 
children  with  perfectly  sound  women.  As  long  ago  as  1861,  Lewin 
found  that  semen  secreted  by  testicles  presenting  no  abnormalities 
except  signs  of  syphilis  contained  spermatozoa  in  only  fifty  per  cent 
of  cases. 

A  few  years  ago  I  had  the  opportunity  of  observing  a  case  which 
well  illustrates  the  effect  of  syphilis  upon  the  generative  organs.  It 
was  that  of  a  man  who  had  lived  in  childless  marriage  two  years, 
although  his  wife  was  perfectly  healthy.  This  man  had  had  syphilis. 
There  were  no  signs  of  disease  upon  his  genital  organs  except  an  old 
unilateral  epididymitis.  The  semen  contained  no  spermatozoa. 
After  a  course  of  energetic  antisyphilitic  treatment  a  few  spermatozoa 
appeared.  After  further  iodine-medication  more  were  found,  and 
finally  his  wife  bore  a  syphilitic  child.  Thus  it  was  demonstrated  that 
azoospermia  may  be  caused  by  constitutional  syphilis  without  any 
signs  of  disease  in  the  testicle  being  present,  and  that  it  may  be  cured 
by  antisyphilitic  treatment. 

Morphinism.  The  excessive  use  of  morphine  occasionally  produces 
azoospermia.  This  is  an  occurrence  to  which  Rosenthal  has  called 
attention.  In  the  case  which  he  described  the  patient  had  taken  from 
0.5  to  0.7  [  I  to  1  gr.]  of  morphine  subcutaneously  every  day  for  the 
relief  of  headache  and  insomnia.  Paralysis  of  the  bladder  developed, 
and  in  the  white  fluid  which  escaped  with  the  last  drops  of  urine  sper- 


THE    RELATION    OF    GENERAL   DISEASES   TO    AZOOSPERMIA.       63 1 

matic  crystals,  but  no  spermatozoa,  were  found.  After  a  protracted 
course  of  treatment,  of  which  the  most  important  part  consisted  in 
the  withdrawal  of  the  morphine,  the  semen  was  found  to  contain  living 
spermatozoa,  although  they  were  not  so  numerous  nor  so  active  as 
they  normally  arc. 

Azoospermia  resulting  from  morphinism,  then,  is  merely  transitory; 
as  the  system  is  freed  from  the  poison  the  testicles  produce  a  function- 
ally potent  secretion. 

Many  other  cases  in  which  men  addicted  to  morphine  have  begotten 


Fig.  230. — Azoospermia,  a.  Dead  spermatozoa,  coiled  and  kinked. 
b.  Molecular  detritus,  c.  Spermatoblasts,  d.  Leucocytes,  c.  Epithe- 
lium.    /.  Flakes  of  pigment. 


children  also  prove  that  the  above  named  action  is  not  constant,  and 
that  it  develops  only  when  a  certain  grade  of  poisoning  is  reached. 

Tuberculosis.  The  widespread  opinion  that  consumptives  usually 
have  numerous  progeny  is  contradicted  by  observations  which  tend 
to  show  that  tuberculosis  exerts  a  deleterious  effect  upon  the  generative 
organs. 

The  result  of  many  observations  shows  that  the  truth  lies  midway 
between  these  opposing  theories.     Tuberculosis  may  rarely  give  rise 


632  FUNCTIONAL    DISTURBANCES    OF    THE    SEXUAL    ORGANS. 

to  azoospermia  and  oligospermia.  In  many  cases,  however,  the  semen 
is  entirely  normal. 

The  diagnosis  of  azoospermia  presents  no  difficulties.  A  drop  of 
fresh  semen  is  placed  under  the  microscope;  absence  of  spermatozoa, 
or  non-activity  of  a  few  which  may  be  present,  and  also  formation  of 
spermatic  crystals,  proves  the  existence  of  azoospermia. 

When  due  to  sexual  excesses  and  general  neurasthenia  the  chances 
of  recovery  are  good. 

Treatment.  The  treatment  of  azoospermia  has  narrow  limits.  If 
due  to  syphilis  then  antisyphilitic  treatment  is  in  place;  in  syphilitic 
epididymitis  local  inunctions  of  mercury,  with  long- continued  internal 
administration  of  potassium  iodide,  are  advantageous. 

Neurasthenia  and  sexual  excesses  require  above  all  things  abstinence 
from  sexual  intercourse,  together  with  the  employment  of  the  measures 
recommended  for  the  treatment  of  impotence  (quod  vide). 

In  morphinism  the  first  requisite  is  the  withdrawal  of  the  drug. 

In  cryptorchidism  there  is  no  treatment.  If  the  patient  is  presented 
for  treatment  very  early  in  life,  the  threatening  arrest  of  development 
in  the  testicles  may  be  prevented  (see  also  under  Cryptorchidism). 

In  gonorrhceal  epididymitis  an  attempt  must  be  made  to  prevent 
extension  of  the  inflammation.  If  thickening  and  hardness  remain, 
a  suspensory  bandage  should  be  worn,  so  that  the  testicle  may  be  ele- 
vated and  fixed.  The  testicle  is  first  enveloped  in  cotton  wet  with  a 
solution  of  aluminum  acetate;  this  is  covered  with  rubber  tissue  and 
the  suspensory  then  put  on.  The  dressing  is  changed  every  day.  It 
should  be  continued  for  months.  The  patient  should  also  take  potas- 
sium iodide  for  a  long  time. 

In  atrophy  of  the  testicle  little  can  be  expected.  Any  treatment 
which  may  be  employed  in  cases  dependent  upon  a  central  lesion  is 
naturally  without  result.  In  cases  due  to  other  causes  electrization  is 
worthy  of  trial.  The  current,  which  is  passed  from  the  positive  pole 
placed  on  the  spine  to  the  negative  laid  upon  the  testicles,  should  be 
weak,  and  should  be  used  for  only  a  few  minutes. 

[Azoospermia  due  to  occlusion  of  the  vas  deferens  resulting  from 
gonorrhceal  inflammation  has  been  treated  by  anastomosing  the  vas 
with  the  head  of  the  epididymis. 

This  procedure  was  first  practised  by  Edward  Martin,  of  Phila- 
delphia. After  experimenting  upon  dogs  he  performed  the  operation 
upon  man  with  apparently  successful  results,  inasmuch  as  the  semen 


THE    RELATION    OF    GENERAL    DISEASES   TO    AZOOSPERMIA.       633 

discharged  nineteen  days  after  operation  contained  motile  spermatozoa. 

Posner  and  Cohen,  of  Berlin,  have  treated  six  cases  by  this  method. 
They  advise  preliminary  puncture  of  the  testicle  in  order  to  determine 
whether  spermatozoa  are  present. 

A  portion  of  the  head  of  the  epididymis  is  excised,  the  vas  opened 
longitudinally  for  the  distance  of  a  quarter  of  an  inch,  and  then  im- 
planted into  the  epididymis  by  means  of  four  very  small  silver-wire 
sutures;  the  sutures  are  introduced  from  the  outer  surface  of  the  vas 
into  its  lumen,  thence  into  the  incision  in  the  epididymis  and  out 
through  its  fibrous  tunic. 

Further  experience  with  this  operation  is  necessary  to  determine  its 
exact  value.  I  consider  it  worthy  of  trial.  The  possibility  of  the 
anastomosis  becoming  closed  by  the  products  of  inflammation  must 
be  taken  into  consideration.] 


NDEX 


Abscess,  of  the  kidney,  497 

of  the  prostate,  311 

peri  urethral,  100 

prevesical,  290 

urinary,  140,  164 
Acetic  acid  and  ferrocyanide  test,  58 
Acetone,  test  for,  63 
Acetonuria,  63 
Achillodynia,  106 
Albumen,  quantitative  estimation  of,  59 

tests  for,  57,  58,  59,  60 
Albuminometer,  59 
Albumosuria,  60 
Alexander's    method   of   prostatectomy, 

37* 
Ammonium  urate,  test  for,  83 
Amputation  of  the  penis,  199 
Aneurysm  of  the  renal  artery,  552 
Angioma  of  the  urethra,  173 
Angioneurosis  renis,  553 
Animal  parasites  in  the  urine,  77 
Anorchism,  effect  upon  virility,  624 
Arthritis,  gonorrhceal,  103 
Aspermatism,  619 

anaesthetic,  623 

atonic,  622 

psychical,  623 
Azoospermia,  624 

etiology  of,  624 

in  relation  to  general  diseases,  628 

physiological,  628 

treatment  of,  632 

Bacteriorrhcea,  89 
Bacteriuria,  74 
Balanitis,  186 
Balanoposthitis,  186 
Beck's  operation  for  hypospadias,  187 
Belfield's  method]of  draining  the  seminal 
vesicles,  457 
of  prostatectomy,  365 
Bevan's  operation  for  retained  testicle, 

412 
Bigclow's  evacuator,  262 
Bile-pigment,  test  for,  64 
Bismuth  test  for  sugar,  61 
Biuret  test,  60 
Bladder,  anatomy  of,  206 


Bladder,  atony  of,  298 

capillary  puncture  of,  158,  342    357 
carcinoma  of,  269 
chorio-epithelioma  of,  268 
curettage  of,  212,  226,  247 
digital  examination  of,  51 
diverticulum  of,  284 
drainage  of,  in  cystitis,  225 
echinococcus  disease  of,  281 
exstrophy  of,  288 
fibroma  of,  268 
foreign  bodies  in,  248 
hernia  of,  284 
inflammation  of,  208 

See  also  under  Cystitis 
injuries  of,  278 
irrigation  of,  223 
malformations  of,  287 
neuroses  of,  290 
papilloma  of,  266 
paralysis  of,  297 
parasites  of,  281 
rupture  of,  279 
sarcoma  of,  268 
stone  in,  250 

See  also  under  Vesical  calculus. 
tuberculosis  of,  226 

cystoscopy  in,  238 

diagnosis  of,  235 

etiology  of,  227 

pathological  anatomy  of,  229 

symptoms  of,  232 

treatment  of,  240 

by  hygienic  measures,  241 
by  internal  medication,  242 
by  local  applications,  243 
by  operative  procedures,  246 
tumors  of,  269 

course,  274 

diagnosis,  273 

etiology,  270 

symptoms,  271 

treatment,  275 
ulcer  of,  283 
varices  of.  287 
wounds  of,  278 
X-ray  examination  of,  52 
Blood-casts,  73 


635 


636 


INDEX. 


Blood  in  the  urine,  significance  of,  5 

test  for,  65 
See  also  under  Hematuria. 
Bottcher's  crystals,  572 
Bottger's  test  for  sugar,  61 
Bottini's  operation,  371 

contraindications  to,  373,  377 

dangers  of,  374,  377 

indications  for,  375 

technic  of,  372 
Bougies  a,  boule,  7 

bayonet,  144 

filiform,  7 

spiral,  144 
Bright's  disease,  482 

See  also  under  Nephritis 
Bubo,  96,  203 
Bullous  oedema,  44,  239 
Bursitis,  gonorrhceal,  105 

Calcium  carbonate,  in  the  urine,  82 

oxalate,  in  the  urine,  80 

phosphate,  in  the  urine,  81 

sulphate,  in  the  urine,  80 
Calculus,  of  the  seminal  vesicles,  460 

prostatic,  386 

renal,  524 

ureteral,  524 

urethral,  169 

vesical,  250 
Cancer,  see  under  Carcinoma. 
Carcinoma,  of  the  bladder,  269 

of  the  kidney,  534 

of  the  penis,  198 

of  the  prostate  gland,  389 

of  the  seminal  vesicle,  461 

of  the  scrotum,  418 

of  the  testicle,  420 

of  the  ureter,  538 

of  the  urethra,  173 
Castration,  technic  of,  426 
Casts,  amyloid,  73 

blood,  73 

epithelial,  73 

false,  74 

fatty,  73 

granular,  72 

hyaline,  71 

leucocyte,  73 

origin  of,  71 

oxalate,  74 

uric-acid,  74 

waxy,  73 
Catheter,  Benique,  10 

bicoudee",  7 

Brodie's,  10 


Catheter,  Casper's,  350 

Gouley's,  154 

Malecot's,  353 

Mercier's,  7 

Nekton's,  6 

olivary,  7 

Pezzer's,  353 

rat -tail,  148 

silk -web,  7 

Ultzmann's  irrigating,  116 
Catheterization,  asepsis  of,  46 

of  the  ureters,  469 

permanent,  355 

technic  of,  10 
Chancroid,  194 

diagnosis  of,  196 

etiology  of,  194 

prognosis  of,  197 

symptoms  of,  194 

treatment  of,  197 

urethral,  129 

varieties  of,  195 
Chimney-sweepers'  cancer,  418 
Chordee,  treatment  of,  no 
Chorio-epithelioma,  of  the  bladder,  268 

of  the  testicle,  421 
Chromocystoscopy,  473 
Chyluria,  64 
Circumcision,  188 
Clap,  90 

See  also  under  Gonorrhoea. 
Cock's  operation  for  retention  of  urine 

158 
Colpocystotomy,  225 
Condylomata,  of  the  penis,  198 

of  the  urethra,  130 
Cowperitis,  101 
Cryoscopy,  of  the  blood,  473 

of  the  urine,  470 
Cryptorchidism,  effect  upon  virility,  624 
Cylindroids  in  the  urine,  74 
Cystic  degeneration  of  the  kidney,  539 

of  the  testicle,  419 
Cystin,  80 
Cystitis,  208 

cystoscopy  in,  42 

definition  of,  208 

diagnosis  of,  218 

due  to  stricture,  140,  216 

due  to  tumors,  217 

etiology  of,  208 

forms  of,  210 

gonorrhceal,  214 

membranous,  218 

pathological  anatomy  of,  211 

prevention  of,  219 


[  N I )  I  \  . 


Cystitis,  symptoms  of,  211 

traumatic,  215 

treatment  of,  219 

by  hygienic  measures,  220 
by  internal  medication,  220 
by  local  measures,  223 
by  operative  procedures,  225 

with  retention  of  urine,  215 
colli,  214 
feminae,  215 
Cystopexy,  359 
Cystoscope,  Albanian's,  32 

Ay  res',  35 

Belfield's,  t,^ 

Bierhoff's,  36 

Bransford  Lewis's  operative,  34 

Bransford  Lewis's  universal,  34 

Brenner's,  30 

Casper's,  32 

F.  Tilden  Brown's,  35 

Giiterbock's,  28 

Hirschmann's,  28 

Nitze's,  26,  28,  29,  32 

Otis's,  34 

operative,  32,  34, 

photographic,  28 

ureteral,  30 

Winter's,  28 
Cystoscopic  picture,  in  calculi,  43 

in  cystitis,  42 

in  foreign  bodies,  43 

in  health,  39 

in  tumors,  43 
Cystoscopy,  22 

asepsis  of,  46 

diagnostic  value  of,  44 

history  of,  22 

in  renal  examinations,  469 

technic  of,  38 

therapeutic  value  of,  46 
Cysts  of  the  kidney,  539 

of  the  prostate  gland,  306 

of  the  seminal  vesicle,  459 

of  the  sinus  pocularis,  306 

of  the  urethra,  173 

Deferenitis,  438 

Diacetic  acid,  test  for,  63 

Dilatation    of   the  urethra,  for  chronic 

gonorrhoea,   124 

contraindications  to,  148 

for  stricture,  142,  146 

limitations  of,  148 
Dilators,  Horwitz's,  155 

Kallmann's,  126 

Oberlander's,  124 


Distoma  haematobium,  78 

of  the  bladder,  2X1 

of  the  kidney,  5  15 
Diverticulum  of  the  bladder,  285 
Duplay's  operation  for  hypospadias,  180 
Dystopia  renis,  477 

Echinococcus  disease  of  the  bladder,  281 

of  the  kidney,  544 

of  the  prostate  gland,  401 
Einhorn's  saccharomcter,  62 
Ejaculation,  mechanism  of,  567 
Electroscope,  Casper's,  12 
Elephantiasis  of  the  female  urethra,  174 

of  the  penis,  201 

of  the  scrotum,  417 
Emissions,  seminal,  573 

pathological,  prognosis  of,  579 

significance  of,  573,  576 

treatment  of,  580 
See  also  under  Sexual  neurasthenia. 
Enuresis,  300 
Epididymis,  anatomy  of,  408 

syphilis  of,  428 

tuberculosis  of,  422 

tumors  of,  419 
Epididymitis,  433 

as  a  cause  of  sterility,  435,  627 

complications  of,  435 

etiology  of,  433 

symptoms  of,  433 

terminations  of,  435 

treatment  of,  436 
Epinephritis,  549 
Epinephroid,  533 
Epispadias,  183 

Epithelioma  of  the  scrotum,  418 
Epithelium,  urinary,  70 
Erection,  mechanism  of,  565 

production  of,  564 
Esbach's  albuminometer,  59 
Essential  haematuria,  553 
Eustrongylus  gigas,  545 
Exanthemata,  gonorrhceal,  ic8 
Exstrophy  of  the  bladder,  288 

Fermentation  test  for  sugar,  62 
Fibroma  of  the  bladder,  268 
Filaria  sanguinis,  77 

of  the  bladder,  281 

of  the  kidney,  546 
Filiform  bougies,  7 
Fistula  of  the  urethra,  [83 

para  urethral,  ioo 
treatment  of,  116 


638 


INDEX. 


Floating  kidney,  541 

See  also  under  Movable  kidney. 
Foetal  kidney,  475 
Folliculitis,  urethral,  101 
Forbes's  lithotrite,  261 
Foreign  bodies  in  the  bladder,  248 

in  the  urethra,  166 
Freyer's  method  of  prostatectomy,  366 
Fuller's  method  of  prostatectomy,  366 
Functional   renal  examination,   general 

considerations,  469 

in  cystic  degeneration  of  the  kidney, 

in  nephrolithiasis,  529 
in  neuralgia  of  the  kidney,  555 
in  pyelitis,  504 
in  pyonephrosis,  515 
in  tuberculosis,  522 
in  tumors,  536 
Funiculitis,  438 

Galactocele,  446 
Gonococcus,  9c 

methods  of  staining,  91 
Gonorrhoea,  90 
causes  of,  90 
complications  of: 

extragenital,  igi 

genital,  100 
diet  in,  109 

infectiousness  of,  99,  127 
of  the  eye,  102 
of  the  mouth,  102 
of  the  rectum,  101 
pathological  anatomy  of,  92 
prognosis  of,  108 
symptoms  of: 

acute,  94 

chronic,  97 
treatment  of: 

acute  anterior,  109 
posterior,  114 

chronic,  116 

by  abortive  measures,  no 

by  dilatation,  124 

by  electrolysis,  126 

by  injections,  112 

by  instillations,  115,  id 8 

by  irrigations,  112,  115,  116,  119 

by  internal  remedies,  109 

by  internal  urethrotomy,  126 

by  mechanical  methods,  124 

by  ointments,  123 
urethroscopy  in,  19,  126 
Gonorrhoea  and  marriage,  99,  127 
Gonorrhceal  achillodynia,  106 


Gonorrhceal  arthritis,  103 

bursitis,  105 

endocarditis,  107 

exanthemata,  108 

folliculitis,  100 

lymphadenitis,  100 

lymphangitis,  100 

myelitis,  106 

myositis,  105 

ophthalmia,  102 

osteomyelitis,  106 

perifolliculitis,  100 

periostitis,  105 

phlebitis,  106 

pleurisy,  106 

prostatitis,  120 

pulmonary  infarct,  106 

tendovaginitis,  105 
Goodfellow's  method  of  prostatectomy, 

366 
Gouley's  tunnelled  catheter,  154 
Grawitz's  tumor,  533 
Guyon's  lithotrite,  261 

syringe,  118 

Harris's  segregator,  474 
Haematocele,  446 
Hsematuria,  essential,  553 
Hsematuria,  general  considerations,  5 

in  acute  nephritis,  485 

in  chronic  nephritis,  487 

in  gonorrhoea,  96 

in  hypertrophy  of  the  prostate,  342 

in  nephrolithiasis,  528 

in  neuralgia  of  the  kidney,  553 

in  renal  tumors,  535 

in  vesical  calculus,  255 

in  vesical  tuberculosis   234 

in  vesical  tumors,  271 
Haemoglobin  in  the  urine,  test  for,  65 
Hemospermia,  618 
Heat-tests  for  albumen,  58 
Heller's  test  for  albumen,  58 
Hernia  of  the  bladder,  284 
Horseshoe  kidney,  475 
Horwitz's  dilator,  155 
Hydrocele,  acute,  439 

chronic,  440 

diagnosis  of,  443 
etiology  of,  441 
symptoms  of,  441 
treatment  of,  444 

congenital,  413 

cystic,  448 

of  the  cord,  448 

of  the  seminal  vesicles,  459 


INDIA'. 


639 


Hydronephrosis,  505 

course  of,  508 

diagnosis  of,  508 

etiology  of,  505 

forms  of,  505 

pathological  anatomy  of,  506 

prognosis  of,  509 

symptoms  of,  507 

treatment  of,  509 
Hydrospermia,  617 
Hydrothionuria,  64 
Hypertrophy  of  the  prostate,  322 

See  also  under  Prostate  gland,  hyper- 
trophy of. 
Hypernephroma,  533 
Hypospadias,  177 

etiology  of,  177 

symptoms  of,  179 

treatment  of,  180 

Impotence,  definition  of,  582 
forms  of,  583 
nervous,  594 
organic,  583 
paralytic,  598 
psychical,  585 
treatment  of,  606 
by  electricity,  613 
by    hydrotherapeutic    measures. 

610,  613 
by  hygienic  measures,  608 
by  internal  medication,  614 
by  local  applications,  613 
by  psychical  methods,  606 
Indican  in  the  urine,  65 
Infiltration  of  urine,  139,  164 
Injuries  of  the  bladder,  278 
of  the  kidney,  550 
of  the  penis,  185 
of  the  prostate  gland,  307 
of  the  scrotum  and  testicle,  414 
of  the  seminal  vesicles,  454 
of  the  urethra,  160 
diagnosis,  162 
treatment,  163 
of  the  ureter,  561 
Irrigation  of  the  bladder,  223 
Irritable  bladder,  294 

Janet's  method  of  irrigation,  no,  115, 119 

Katheterpurin,  50 
Keyes-Ultzmann  syringe,  118 
Kidneys,  amyloid  degeneration  of,  495 

anatomy  of,  462 

arteriosclerotic,  49 t,  493 


Kidneys,  circulatory  disturbam  ea  of,  480 

contracted,  492,  493 
contusions  of,  55  1 
cyanotic  induration  of,  .480 
cystic  degeneration  of,  539 
cysts  of,  539 

echinococcus,  544 
diffuse  hematogenous  non-suppur- 

ative  inflammation  of,  482 
dystopia  of,  477 
echinococcus  disease  of,  544 
examination  of,  467 
fatty,  496 
floating,  541 
fcetal,  475 

functional  examination  of,  469 
haemorrhagic  infarct  of,  481 
histology  of,  466, 
horsesho.e,  475 
hyperemia  of,  480 
inflammation  of,  483,  497 

See  under  Nephritis,  Pyelitis,  <  tt . 
injuries  of,  550 
malformations  of,  475. 
movable,  541 
neuralgia  of,  553 
parasites  of,  544 
physiology  of,  466 
suppuration  in,  497,  510 
syphilis  of,  546 
tuberculosis  of,  517 

diagnosis  of,  521 

etiology  of,  517 

functional  renal  test  in,  522 

pathological  anatomy  of,  518 

prognosis  of,  522 

symptoms  of,  520 

treatment  of,  523 

urine  in,  520,  522 
tumors  of,  533 

diagnosis  of,  536 

functional  renal  examination  in, 

536 

pathological  anatomy  of,  533 

prognosis,  537 

symptoms,  534 

treatment,  538 

urine  changes  in,  535 
Koch's  urethroscope,  14 
Kollmann's  dilators,  126 

LeFort's  method  of  dilating  strictures, 

147,  148 
Leucin,  80 

Libido  scxualis,  nature  and  causes  of,  567 
Lipuria,  64 


640 


INDEX. 


Litholapaxy,  260 
Lithotripsy,  260 
Lithotomy,  264 
Lohnstein's  saccharometer,  62 
Lubricants,  49 
Luys'  segregator,  473 
Lymphadenitis,  203,  100 
Lymphangitis,  100,  no,  202 

Maisonneuve's  urethrotome,  151 
Magnesium  phosphate,  in  the  urine,  82 
Malformations  of  the  bladder,  287 

of  the  kidneys,  475 

of  the  scrotum,  409 

of  the  seminal  vesicles,  454 

of  the  urethra,  176 
Massage  of  the  prostate,  122,  319 
Masturbation,  as  a  cause  of  spermator- 
rhoea, 575 

effects  of,  575 

prevention  of,  580 
McGilPs  method  of  prostatectomy,  365 
Megaloscope,  28 
Micrococcus  ureae,  76 
Micturition,  frequency  of,  2 

in  health,  2 

in  disease,  3 

mechanism  of,  291 
Moore's  test,  62 
Morphinism,  as  a  cause  of  azoospermia, 

630 
Movable  kidney,  541 

diagnosis  of,  542 

etiology  of,  541 

prognosis  of,  543 

symptoms  of,  542 

treatment  of,  543 
Myelitis,  gonorrhceal,  106 
Myositis,  gonorrhceal,  105 

Nephralgia,  553 
Nephrectomy,  abdominal,  5^9 
lumbar,  559 
partial,  560 
Nephritis: 

acute  diffuse,  483 

etiology  of,  483 

palhological  anatomy  of,  484 
prognosis  of,  485 

symptoms  of,  485 

treatment  of,  486 

urine  in,  485 
chronic,  486 

cardiac  condition  in,  488 

dropsy  in,  488 

etiology  of,  486 


Nephritis,  chronic,  forms  of,  490 

pathological  anatomy  of,  489 

prognosis  of,  493 

symptoms  of,  487,  492 

treatment  of,  493 

uraemia  in,  488 

urine  in,  487,  491,  492 

of  pregnancy,  494 

suppurative,  497 

syphilitic,  546 
Nephrolithiasis,  524 

colic  in,  527 

diagnosis  of,  528 

etiology  of,  524 

functional  renal  test  in,  529 

pathological  anatomy  of,  524 

prognosis  of,  530 

symptoms  of,  527 

treatment  of,  531 

urine  in  528 
Nephrotomy,  technic  of,  556 
Neuralgia  of  the  kidney,  553 
Neurasthenia,  sexual,  577 
Neuroses  of  the  bladder,  290 

of  the  kidney,  553 

of  the  prostate,  403 

sexual,  577* 
Nicoll's  method  of  prostatectomy,  371 
Nitric  acid  test  for  albumen,  58 
Nitze's  cystoscopes,  26,  28,  29 

Oberlander's  dilators,  124 
Ointments,  urethral,  124 
Oligospermia,  617 
Orchitis,  acute,  430 

chronic,  432 
Orgasm,  definition  of,  567 
Osteomyelitis,  gonorrhceal,  106 
Otis-Kreisl  urethrotome,  126 
Otis  urethrometer,  98 

Papilloma  of  the  bladder,  266 

of  the  urethra,  172 
Paranephritis,  549 
Paraphimosis,  192 
Parasites  of  the  bladder,  281 

of  the  kidney,  544 

of  the  prostate  gland,  401 
Paraurethral  fistula,  100 

treatment  of,  116 
Penicillium  glaucum,  75 
Penis,  amputation  of,  199 

carcinoma  of,  198 

cavernous  induration  of.  201 

cavernous  infiltration  of,  201 

condylomata  of,  198 


IM'I.X. 


64I 


Penis,  elephantiasis  of,  201 
injuries  of,  185 
luxation  of,  185 
tumors  of,  198 
Pericowperitis,  101 
Perifolliculitis,  101 
Perinephritis,  549 
Periostitis,  gonorrhceal,  105 
Periprostatic  phlegmon,  313 
Periurethral  abscess,  100 
Phimosis,  187 
Phlebitis,  gonorrhceal,  106 

periprostatic,  313 
Phloridzin  test,  469 
Pollutions,  seminal,  573 

See  also  under  Emissions,  seminal. 
Polypi,  urethral,  172 
Polyspermia,  617 
Post-gonorrhceal  chorea,  107 
Potassium  urate,  78 
Prevesical  phlegmon,  290 

space,  206 
Propeptonuria,  60 
Prostate  gland,  abscess  of,  311 
absence  of,  305 
anatomy  of,  303 
atrophy  of,  305 
carcinoma  of,  389 
calculus  of,  386 
concretions  of,  386 
cysts  of,  306 

echinococcus  disease  of,  401 
hypertrophy  of,  322 
complications  of,  341 
cystoscopy  in,  346 
diagnosis  of,  346 
etiology  of,  325 
forms  of,  322 

pathological  anatomy  of,  327 
prognosis  of,  348 
symptoms,  336 
treatment,  348 

by  the  Bottini  operation,  371 

by  catheterization,  349 

by  cystopexy,  359 

by  double  castration,  361 

by  ligation  of  the  internal  iliac 

arteries,  361 
by  perineal  prostatectomy,  369 
by  suprapubic  prostatectomy, 

365 

by  vasectomy,  363 

summary  of,  379 
inflammation  of,  308 

See  also  under  Prostatitis. 
injuries  of,  307 


Prostate  gland,  massage  of,  122  319 
neuroses  of,  403 
parasites  of,  401 
physiology  of,  303 
sarcoma  of,  392 
syphilis  of,  400 
tuberculosis  of,  379 
diagnosis  of,  384 
etiology  of,  379 
pathological  anatomy  of.  381 
prognosis  of,  384 
symptoms  of,  382 
treatment  of,  384 
tumors  of,  389 
diagnosis  of,  393 
pathological  anatomy  of,  390 
symptoms  of,  393 
treatment  of,  397 
Prostatectomy,  365 

combined  method  of,  371 
concraindications  to,  368 
indications  for,  366 
mortality  after,  367,  371 
partial,  365 
perineal,  369 
suprapubic,  365 
sequelae,  367,  371 
Prostatic  abscess,  311 
Prostatic  secretion,  effect  upon  sperma- 
tozoa, 571 
Prostatismus,  359 
Prostatitis: 

acute,  309,  120 
catarrhal,  309 
follicular,  309 
parenchymatous,  310 
suppurative,  311 
treatment  of,  313 
chronic,  314 

etiology  of,  314 
diagnosis  of,  315 
pathological  anatomy  of,  314 
symptoms  of,  315 
treatment  of,  122,  319 
Prostatorrhcea,  317 
Prostatotomy,  galvano-caustic,  371 
Psoriasis  mucosa,  21 
Psychrophore,  613 
Pubo-vesical  ligaments,  206 
Pulmonary  infarct,  gonorrhceal,  106 
Pyelitis,  497 

etiology  of,  497 

functional    renal    examination    in, 

5°4 
pathological  anatomy  of,  498 
prognosis  of,  504 


642 


INDEX. 


Pyelitis,  symptoms  of,  500 

treatment  of,  504 

urine  in,  502 
Pyelonephritis,  497 

See  also  under  Pyelitis. 

in    hypertrophy    of    the    prostate, 

343 

Pyonephrosis,  510 

condition  of  ureters  in,  513 

diagnosis  of,  515 

etiology  of,  511 

forms  of,  510 

functional  renal  test  in,  515 

pathological  anatomy  of,  511 

prognosis  of,  516 

symptoms  of,  514 

treatment  of,  516 

urine  in,  514 
Pyospermia,  617 

Radioscopy,  52 

in  renal  examinations,  468 

in  vesical  calculus,  257 
Rectum,  gonorrhoea  of,  101 
Renal  artery,  aneurysm  of,  552 

thrombosis  and  embolism  of,  481 
Renal  calculus,  524 
Renal  colic,  527 

treatment  of,  531 
Renal  pelvis,  tumors  of,  538 
Resection  of  the  urethra,  156 
Retention  of  the  testicle,  410 
Retention  of  urine,  due  to  cysts  of  the 
sinus  pocularis,  306 

due  to  prostatic  hypertrophy,  338 

due  to  stricture,  138 
treatment  of,  156 
Retzius  space  of,  206 
Robbins'  ointment  applicator,  123 

Saccharometer,  62 
Saccharomyces  in  the  urine.  75 
Sarcoma  of  the  bladder,  268 

of  the  kidney,  533 

of  .the  prostate  gland,  392 

of  the  seminal  vesicle,  461 

of  the  testicle,  419 
Scrotum,  carcinoma  of,  418 

congenital  diseases  of,  409 

eczema  of,  416 

elephantiasis  of,  417 

epithelioma  of,  418 

erysipelas  of,  417 

injuries  of,  414 

oedema  of,  416 

open  wounds  of,  416 


Scrotum,  phlegmon  of,  417 

tumors  of,  417 
Secretions,  examination  of,  55 
Segregators,  473 
Semen,  abnormal  loss  of,  573 

composition  of,  569 

pathology  of,  617 

properties  of,  569 
Seminal  crystals,  572 
Seminal  emissions,  573 
Seminal  vesicles,  acute  inflammation  of 

455 

anatomy  of,  452 

calculi  of,  460 

carcinoma  of,  461 

chronic  inflammation  of,  456 

concretions  of,  460 

cysts  of,  459 

drainage  of,  457 

examination  of,  453 

hydrocele  of,  459 

injuries  of,  454 

irrigation  of,  457 

malformations  of,  454 

physiology  of,  452 

tuberculosis  of,  457 
Sexual  neurasthenia,  577 

in  relation  to  azoospermia,  629 

prognosis  of,  579 

symptoms  of,  578 

treatment  of,  580 
Sexual  organs,  physiology  of,  564 

See    also    under  Aspermatism,  Impo- 
tence, Neurasthenia,  etc. 
Sinus  pocularis,  cysts  of,  306 
Sodium  urate,  78 
Sounds,  varieties  of,  6 
Space  of  Retzius,  206 
Spermatic  cord, 

anatomy  of,  409 

hydrocele  of,  448 

inflammation  of,  438 

torsion  of,  415 

varix  of,  449 
Spermatic  crystals,  572 
Spermatocele,  447 
Spermatocystitis,  acute,  455 

chronic,  456 
Spermatorrhoea,  definition  of,  574 

diagnosis  of,  576 

etiology  of,  575 

prognosis  of,  579 

treatment  of,  580 
See  also  under  Sexual  neurasthenia. 
Spermatozoa,  characteristics  of,  570 

effect  of  chemicals  upon,  570 


INDEX. 


643 


Spermatozoa,  effect  of  pus  upon,  627 
Sterility,  616 

due  to  defect  or  deformity,  618 
due  to  aspermatism,  619 
due  to  azoospermia,  624 
due  to  prostatic  abscess,  312 
forms  of,  619 
See  also  under  Aspermatism,  Azoospei'- 
mia,  and  Epididymitis. 
Stone-searcher,   10 
Stone-sound,  10 
Stone-crushing,  260 

See  also  under  Vesical  Calculus. 
Stricture,  of  the  female  urethra,  159 
of  the  male  urethra,  131 
conception  of,  131 
cystitis  due  to,  140 
definition  of,  131 
diagnosis  of,  138 
etiology  of,  132 
hypersensibility  of  the  urethra  in, 

149 
location  of,  136 
pathological  anatomy  of,  133 
prognosis  of,  140 
recurrence  of,  159 
resilient,  149 
site  of,  136 
symptoms  of,  137 
treatment  of,  141 
by  dilatation, 
continuous,  146 
gradual,  142 
by  divulsion,  141 
by  electrolysis,  141 
by  external  urethrotomy,  153 
by  internal  urethrotomy,  150 
by  resection  of  the  urethra,  156 
valvular,  134 
urinary  stream  in,  138 
Struma  suprarenalis,  533 
Sugar,  tests  for,  61,  62 
Sulpho-salicylic  acid  test,  59 
Swinburne's  urethroscope,  15 
Syme's  staff,  154 

Syphilis,  as  a  cause  of  azoospermia,  630 
of  the  epididymis,  428 
of  the  kidney,  546 
of  the  prostate,  382 
of  the  testicle,  428 
of  the  urethra,  130 


Teale's  gorget,  155 
Tendovaginitis,  gonorrhoea! ,  105 
Teratoma  of  the  testicle,  420 
Testicles,  anatomy  of,  408 


Testicles,  atrophy  of,  as  a  cause  of  sterility 
624 

carcinoma  of,  420 

chorio  epithelioma  of,  421 

congenital  diseases  of,  410 

cystic  disease  of,  419 

gangrene  of,  415,  416 

inflammation  of,  430 

injuries  of,  414 

open  wounds  of,  416 

retention  of,  410 

sarcoma  of  419 

syphilis  of,  428 

teratoma  of,  420 

tuberculosis  of,  422 

tumors  of,  419 

wounds  of,  416 
Thompson's  lithotrite,  260 

urethrotome,  151 
Torrey's  antigonococcic  serum,  104 
Triangular  ligament,  88 
Trichomonas  vaginalis,  77 
Trigonum  vesicale,  206 
Trigonum  of  Lieutaud,  206 
Trommer's  test  for  sugar,  61 
Tuberculin,  value  of,  233 
Tuberculosis  of  the  bladder,  226 

of  the  epididymis,  422 

of  the  kidney,  517 

of  the  prostate  gland,  379 

of  the  seminal  vesicles,  457 

of  the  testicle,  422 

of  the  ureter,  562 

of  the  urethra,  175 
See  also  under  the  various  organs. 
Tuberculosis,  as  a  cause  of  azoospermia, 

631 
Tumors  of  the  bladder,  269 

of  the  kidney,  534 

of  the  penis,  198 

of  the  prostate  gland,  389 

of  the  renal  pelvis,  538 

of  the  scrotum,  418 

of  the  seminal  vesicle,  461 

of  the  testicle,  420 

of  the  tunica  vaginalis,  418 

of  the  ureter,  538 

of  the  urethra,  173 
Tunica  vaginalis,  tumors  of,  418 

See  also  under  Hydrocele. 
Tyrosin,  80 

Ulcer  of  the  bladder,  283 
Ulcus  molle,  T94 
Ultzmann's  catheter,  116 
Urachus,  anomalies  of,  289 


644 


INDEX. 


Uraemia,  488 

treatment  of,  494 
Ureters,  calculi  of,  562 

catheterization  of,  469 

examination  of,  560 

fistulas  of,  561 

inflammation  of,  561 

injuries  of,  561 

tuberculosis  of,  562 

tumors  of,  538 
Ureteral  anastomosis,  561 

calculus,  562 
Urethra,  anatomy  of,  85 

angioma  of,  173 

caliber  of,  86 

calculi  of,  169 

carcinoma  of,  173 

chancroid  of,  129 

condylomata  of,  130 

cysts  of,  173 

elephantiasis  of,  174 

fistula  of,  183 

foreign  bodies  in,  166 

injuries  of,  160 

length  of,  86 

malformations  of,  176 

papilloma  of,  172 

polypus  of,  172 

prolapse  of,  175 

relations  of,  to  true  pelvis, 

resection  of,  156 

stricture  of,  131 

See  also  under  Stricture. 

syphilis  of,  130 

tuberculosis  of,  175 

tumors  of,  172 
Urethral  calculi,  169 

fever,  149 

forceps,  168 

ointments,  124 
Urethritis,  bacterial,  89 

causes  of,  88 

definition  of,  88 

gonorrhceal,  90 

herpetic,  89 

simple,  89 

specific,  90 
Urethrocele,  175 
Urethrometer,  Otis',  88,  98 
Urethrorrhcea,  89 
Urethroscopes,  12 

Casper's,  13 

Koch's,  14 

Swinburne's,  15 

Valentine's,  13 
Urethroscopy,  12 


Urethroscopy,  asepsis  of,  46 

history  of,  13 

in  chancre,  2r 

in  psoriasis  mucosa,  21 

in  tumors,  21 

in  ulcerations,  21 

in  chronic  urethritis,  19 

limitations  of,  15 

technic  of,  16 
Urethrotome,  Maisonneuve's,   151 

Otis-Kreisl,  126 

Thompson's  151 
Urethrotomy,  external,  153 

internal,  150 
dangers  of,  153 
for  chronic  gonorrhoea,  126 
for  stricture,  150 
Uric  acid,  tests  for,  79 
Urinary  abscess,  140,  164 

casts,  71 

See  also  under  Casts. 

haemorrhage,  5 

microorganisms,  74 

stream,  changes  in,  3 
in  stricture,  138 
Urination,  frequency  of,  2 

in  health,  2 

in  disease,  3 

mechanism  of,  291 
Urine,  accidental  contamination  of,  83 

acetone  in,  63 

admixture  of  blood  with,  5 
See  also  under  Hematuria. 

albumen  in,  57 

albumose  in,  60 

animal  parasites  in,  77 

bedside  examination  of,  67 

bile  pigment  in,  64 

blood  in,  test  for,  65 

blood  corpuscles  in,  68 

casts  in,  71 

calcium  carbonate  in,  82 

calcium  oxalate  in,  80 

calcium  phosphate  in,  81 

chemical  examination  of,  57 

composition  of,  55 

diacetic  acid  in,  63 

effect  of  certain  drugs  on,  65 

epithelium  in,  70 

estimation  of  solids  in,  56 

fat  in,  64 

haemoglobin  in,  test  for,  65 

indican  in,  65 

infiltration  of,  139,  164 

magnesium  phosphate  in,  82 

microorganisms  in,  74 


IMtKX. 


645 


Urine,  microscopic  examination  of,  68 

organized  sediments  of,  68 

parasites  in,  77 

physical  properties  of,  55 

propeptone  in,  60 

reaction  of,  56 

retention  of,   due  to  cysts   of   the 
sinus  pocularis,  306 
due  to  prostatic  hypertrophy,  338 
due  to  stricture,  138 

saccharomyces  in,  75 

sugar  in,  61 

sulphuretted  hydrogen  in,  64 

unorganized  sediments  of,  78 

yeast-cells  in,  75 
Urine  segregators,  473 
Urates,  tests  for,  79,  83 
Uro-genital  diaphragm,  88 

Valentine's  urethroscope,  13 
Varices  of  the  bladder,  287 
Varicocele.  449 

treatment  of,  451 
Vas  deferens,  inflammation  of,  438 
Vaso-epididymostomy,  632 
Vesical  calculus,  250 


Vesical  calculus   chemical   examination 

of,  252 

composition  of,  250,  251 

diagnosis  of,  256 

etiology  of,  250 

prognosis  of,  259 

symptoms  of,  254 

radioscopy  in  diagnosis  of,  257 

treatment  of,  259 

urine  in,  255 
Vesiculitis,  acute,  455 

chronic,  456 

Watson's  method  of  prostatectomy,  365 
Winternitz's  psychrophore,  613 

Xanthin,  80 

X-ray,  diagnosis  by,  52 

in  prostatic  hypertrophy,  360 
in  renal  examinations,  468 
in  vesical  calculus,  257 

Yeast-cells,  in  the  urine,  75 
Young's  ointment  applicator,  123 
method- of  prostatectomy,  369 
operation  for  carcinoma  of  the  pros- 
tate, 399 


COLUMBIA    UNIVERSITY    LIBRARIES 


This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 


DATC  BORROWED 

DATE  DUE 

l_— — .1                        = 

DATE  BORROWED 

DATE  DUE 

C28  (747)  MIOO 

